Ophthalmology ICD-10-CM codes

Cataract codes are per eye: H25.11 and H25.12 for right and left age-related nuclear cataract, H25.13 bilateral. After surgery the operated eye becomes pseudophakic (Z96.1), so a patient with one eye done carries the cataract code for the remaining eye plus Z96.1. Routine vision exams use Z01.00 without abnormal findings or Z01.01 with them; refractive diagnoses (H52.13 myopia, H52.03 hypermetropia, H52.223 astigmatism, H52.4 presbyopia) accompany the refraction service.

Glaucoma codes carry laterality and a stage character, and the stage must match the documented visual field and nerve findings: H40.1131 is bilateral primary open-angle glaucoma, mild stage, and H40.1132 moderate stage. H40.9 (unspecified glaucoma) on an established glaucoma patient invites review. Family history of glaucoma (Z83.511) supports the extended testing performed on suspects.

Diabetic eye disease uses the diabetes combination codes, not standalone retina codes: E11.319 for Type 2 diabetes with unspecified retinopathy without macular edema, E11.36 for diabetic cataract, and the more specific E11.32 to E11.35 series by severity and macular edema status. Report E11.9 with a normal-exam finding only when no retinopathy exists; the exam is still billed under the diabetes code as the reason for the encounter.

High-volume medical visits cluster around dry eye (H04.123 bilateral lacrimal), blepharitis (H01.009), conjunctivitis (H10.33 acute bilateral, H10.9 unspecified), chalazion (H00.19), posterior vitreous detachment and floaters (H43.811 to H43.813, H43.393), epiretinal membrane (H35.371 to H35.373), and macular degeneration (H35.30 when stage and type are not documented).