Cataract ICD-10-CM codes

Age-related (senile) cataract is category H25, divided by morphology: H25.0- incipient (cortical H25.01-, anterior subcapsular H25.03-, posterior subcapsular H25.04-), H25.1- nuclear, H25.2- morgagnian, H25.81- combined forms, H25.89 other, and H25.9 unspecified age-related cataract. Nuclear sclerosis indexes to H25.1-, so H25.13 (age-related nuclear cataract, bilateral) is one of the most assigned eye codes.

Laterality is carried in the final character. Five-character codes such as H25.1- use 0 for unspecified eye, 1 right, 2 left, and 3 bilateral. Six-character codes such as H25.01- use 1 right, 2 left, 3 bilateral, and 9 unspecified eye. When a patient has a nuclear cataract in one eye and a cortical cataract in the other, assign a code for each eye rather than a bilateral code.

Category H26 covers non-age-related cataracts: H26.0- infantile and juvenile, H26.1- traumatic, H26.2- complicated, H26.3- drug-induced, H26.4- secondary (H26.49- includes after-cataract and posterior capsule opacification following surgery), and H26.9 unspecified cataract. H28 is cataract in diseases classified elsewhere with the underlying condition coded first, but diabetic cataract uses the diabetes combination code E11.36 instead.

After cataract extraction, report the status codes Z98.41 (right eye) or Z98.42 (left eye) and Z96.1 (presence of intraocular lens) when relevant to the encounter. Once the lens is removed, the cataract code is no longer assigned for that eye.