Dry Eye Syndrome ICD-10-CM codes

Dry eye syndrome is H04.12- (disorder of the lacrimal gland) with laterality in the sixth character: H04.121 right, H04.122 left, H04.123 bilateral, H04.129 unspecified. Dry eye is usually bilateral, so H04.123 is the most common assignment. Tear film insufficiency and dry eye disease both index here.

Keratoconjunctivitis sicca is a trap. The index entry for keratoconjunctivitis sicca defaults to Sjogren syndrome (M35.0-), and only the subentry not Sjogren's goes to H16.22- (H16.223 bilateral). H16.22 also carries an Excludes1 note against M35.01. So H16.22- should be assigned only when the provider documents that the condition is not Sjogren related; otherwise query, because coding M35.01 from the phrase keratoconjunctivitis sicca alone assigns a systemic autoimmune disease the patient may not have.

Sjogren syndrome with keratoconjunctivitis is a combination code, M35.01, and the dry eye is not coded separately. Meibomian gland dysfunction and blepharitis (H01.0-) are frequent contributors and are coded in addition when documented. Exposure keratopathy from lagophthalmos (H02.20-) is a distinct diagnosis.