ICD-10-CM Billable Code

H11.031

Double pterygium of right eye

Clinical Classification Guidelines

Medical Intelligence & Overview

Double pterygium in the right eye refers to the abnormal growth of tissue on the conjunctiva, the clear tissue covering the white of the eye. Specifically, it involves two pterygia, which are wedge-shaped, fleshy growths extending onto the cornea. This condition can affect vision and eye comfort, making awareness and management important.

Causes & Symptoms

Clinical Causes: Prolonged exposure to ultraviolet (UV) sunlight Chronic eye irritation due to dust, wind, or smoke Genetic predisposition Exposure to environmental pollutants Previous eye injuries or surgeries

Key Symptoms: Growth of flesh-colored tissue on the cornea and conjunctiva Redness and irritation in the affected eye A feeling of dryness or foreign body sensation Blurred vision if the growth encroaches onto the cornea Possible swelling or inflammation around the growth

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a comprehensive eye examination. An eye care professional will examine the eye with slit-lamp microscopy to assess the size, location, and extent of the pterygia. Additional imaging tests might be used to evaluate the impact on the cornea and visualize tissue growths more clearly. The diagnosis of double pterygium indicates the presence of two separate or adjacent growths on the conjunctiva and cornea of the right eye.

Treatment Protocols: Treatment options depend on the size and symptoms caused by the pterygium. Common approaches include: - **Observation**: Small, asymptomatic pterygia may just be monitored over time. - **Medications**: Use of lubricating eye drops and anti-inflammatory eye drops can help alleviate irritation and inflammation. - **Surgical removal**: For growing pterygia that threaten vision or cause significant discomfort, surgical excision may be recommended. The procedure aims to remove the abnormal tissue and restore the eye’s appearance and function. - **Postoperative care**: Includes the use of medications to prevent recurrence and support healing. Prevention strategies involve protecting the eyes from UV exposure by wearing sunglasses, using protective hats, and avoiding excessive environmental irritants.

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is H11.031 a billable ICD-10 code?
Yes, H11.031 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report H11.031?
Clinical documentation must specify the nature of Double pterygium of right eye and any associated comorbidities for accurate reporting.

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