The most common codes that will be used in Primary Care are related to conjunctivitis. The two categories related to conjunctivitis are found in the table below, but the most commonly used codes are:
• H10.0 Mucopurulent conjunctivitis
• H10.01- Acute follicular conjunctivitis
• H10.02- Other mucopurulent conjunctivitis
• H10.1- Acute atopic conjunctivitis
• H10.2 Other acute conjunctivitis
• H10.21- Acute toxic conjunctivitis
• H10.22- Pseudomembranous conjunctivitis
• H10.23- Serous conjunctivitis, except viral (B30.-)
• H10.3- Unspecified acute conjunctivitis
• H10.4 Chronic conjunctivitis
• H10.40- Unspecified chronic conjunctivitis
• H10.41- Chronic giant papillary conjunctivitis
• H10.42- Simple chronic conjunctivitis
• H10.43- Chronic follicular conjunctivitis
• H10.44 Vernal conjunctivitis
• H10.45 Other chronic allergic conjunctivitis
Examples:
• Conjunctivitis: H10
• Dry Eye: H04
• Glaucoma: H40
• Retinal Disorders: H33, H34, H35
• First three digits after decimal
• Position 4, or 4 & 5: One or two digits indicating the etiology, or cause, of the condition, e.g., chronic allergic (cause) for conjunctivitis (category).
• Next, one digit that gives location, i.e., which eye:right, left, or bilateral (both).
o While a laterality location code is not required for every diagnosis, we will see it on most eye codes.
o A few codes require location be noted by lid rather than eye.
o Laterality code will be in position 5 or 6,depending upon if there are 1 or 2 digits before denoting cause.
Billing scenario
A patient who is being followed by her Ophthalmologist during the post-op of cataract surgery comes in for an additional visit because she has developed conjunctivitis. The conjunctivitis is unrelated to the cataract surgery and necessitated an additional visit over and above her regular post-op check-ups. The E/M code for the visit is billed to the insurance carrier with a -24 modifier and the diagnosis code used is 372.02 for Acute Conjunctivitis.
Modifier – 24: ICD-10
1. H10.012 Acute conjunctivitis: acute follicular, LEFT eye
2. H26.121 Traumatic cataract: partially resolved RIGHT eye
A54.30 Gonococcal infection, eye, unspecified
A54.31 Gonococcal conjunctivitis
A54.32 Gonococcal iridocyclitis
A54.33 Gonococcal keratitis
A54.39 Gonococcal eye infection, other
H10.***: Conjunctival conditions EyeCodingForum.com 19
H10.011 Acute follicular conjunctivitis, right eye
H10.021 Other mucopurulent conjunctivitis, right eye
H10.11 Acute atopic conjunctivitis, right eye
H10.211 Acute toxic conjunctivitis, right eye
H10.221 Pseudomembranous conjunctivitis, right eye
H10.231 Serous conjunctivitis, except viral, right eye
H10.31 Unspecified acute conjunctivitis, right eye
H10.401 Unspecified chronic conjunctivitis, right eye
H10.***: Conjunctival conditions
• Pingueculitis is an inflammed pinguecula [ H11.151].
H10.411 Chronic giant papillary conjunctivitis (GPC), right eye
H10.421 Simple chronic conjunctivitis, right eye
H10.431 Chronic follicular conjunctivitis, right eye
H10.501 Unspecified blepharoconjunctivitis, right eye
H10.511 Ligneous conjunctivitis, right eye
H10.521 Angular blepharoconjunctivitis, right eye
H10.531 Contact blepharoconjunctivitis, right eye
H10.811 Pingueculitis, right eye
Allergic conjunctivitis is uncomfortable enough on its own, and the addition of contact lenses tends to further exacerbate the problem. Most of your contact lens wearers will hate the idea of switching back to their glasses for allergy season, so consider some alternatives to making the switch from contacts to glasses.
We see many patients who present to our offi ces with complaints of red eye, or “pink eye,” as they like to call it. Sportscaster Bob Costas came down with a case of it during last month’s 2014 Winter Olympics that made headlines worldwide. While the majority of red eye presentations are caused by various types of conjunctivitis—which is the emphasis of this discussion—it is important to fi rst rule out other possible etiologies prior to initiating treatment for conjunctivitis. The primary types of conjunctivitis are bacterial, viral, allergic and Chlamydial—with viral and allergic being the most common. A careful evaluation of the patient’s symptoms and clinical signs should enable the practitioner to arrive at a proper diagnosis.
It is important to fi rst determine the type of conjunctivitis present before selecting the most appropriate treatment. This depends on the practitioner’s ability to accurately assess the patient’s symptoms and distinguish the clinical signs. Both of these tasks can pose signifi cant challenges for the clinician.
It is usually best to have the patient defi ne itching. For example, ask the patient if the sensation they feel itches like a mosquito bite. Many patients use itching as a broader term and actually may be experiencing a mild scratchiness, which would be more consistent with an infectious process or ocular surface disease, rather than allergic conjunctivitis.
Another challenge is the overlap of a patient’s symptoms. For example, the chemical mediators released by chronic allergic conjunctivitis may induce a superficial punctate keratitis, which becomes more symptomatic than the original itching complaint. Additionally, keep in mind that itching of the eye itself is the hallmark sign of allergic conjunctivitis. Itching of the eyelids or lid margins may stem from etiologies related to lid disease rather than allergy
A thorough evaluation of the red eye needs to discern whether the redness is due to hyperemia of the superfi cial conjunctival vessels or injection of the deeper episcleral and/or scleral vessels. Conjunctival hyperemia may indicate an increased permeability of these vessels, leading to the exudative response. Conjunctivitis alone typically does not induce limbal injection. If a determination can not be made solely with slit-lamp observation, the practitioner can always instill a vasoconstrictor and look for blanching of the vessels. Conjunctival vessels will blanch completely, episcleral vessels may partially or totally blanch and scleral vessels will not blanch at all.
Most conjunctivitis cases exhibit an exudative response. Findings may include serous production (i.e., tearing); mucoid, mucopurulent or purulent discharge; fi brinous material or hemorrhage. The serous response may also lead to conjunctival chemosis. Serous discharge or excessive tearing is usually seen with allergic, toxic or viral conjunctivitis, while mucopurulent and/or purulent exudate
is more associated with bacterial and Chlamydial conjunctivitis.
Excessive mucous can be generated in any type of conjunctivitis, depending upon the severity of the infl ammatory response and irritation to the conjunctival goblet cells. Pseudomembrane formation is due to fi brin in the exudative material; it indicates a higher degree of infl ammation.
Pseudomembrane material should always be removed, as there is risk of it becoming a true conjunctival membrane. This risk is due to delayed healing of the infl amed tissue secondary to decreased extracellular fi brinolysis. Pseudomembranes are most frequently associated with epidemic keratoconjunctivitis adenoviral disease, but can also be seen with certain bacterial conjunctivitis, such as streptococcal pneumonia or Gonococcus infection. The presence of pseudomembranes always indicates a need for topical steroids as part of the treatment plan. Conjunctival hemorrhages can be seen with any infectious etiology
Tissue findings in conjunctivitis can manifest as either a papillary or follicular response. Papillae, typically seen in bacterial infection as a response to chronic irritation or allergy, are raised tissue masses found on the palpebral conjunctiva with a central vessel and are created by a focal infi ltration of infl ammatory cells. The type of infl ammatory cell depends on the underlying etiology—for example, eosinophils in allergic conditions vs. neutrophils in bacterial disease.
Follicles represent expansions of the lymph system with a blisterlike appearance and a central avascular zone with the conjunctival vasculature otherwise following its normal course over the follicle. Follicles are seen in viral, Chlamydial and toxic conditions. In viral conjunctivitis, follicles form in response to viral particles having entered the lymph system, which also creates the localized preauricular lymph node response.
The clinical evaluation of conjunctivitis should also include an assessment of the eyelids, cornea and relevant lymph nodes. Eyelid edema can be seen with any type of conjunctivitis, depending on the severity of the infl ammatory response. While most presentations of conjunctivitis do not affect the cornea, a careful corneal assessment should be performed to rule out any associated punctate keratopathy, dendrites or corneal infi ltrates. Their presence may illuminate a more precise diagnosis or help to better explain patient symptoms. For example, an associated punctate keratopathy may explain the patient’s complaints of a gritty or scratchy feeling.
The preauricular and submaxillary lymph nodes should always be palpated to rule out enlargement and/or tenderness during a workup for conjunctivitis. Both fi ndings can be associated with viral or Chlamydia infection.
Other cases where laboratory diagnostic testing may be of higher value include suspected MRSA or MRSE infection, chronic conjunctivitis unresponsive to treatment, conjunctivitis potentially secondary to canaliculitis or dacryocystitis, and hyperacute conjunctivitis if Gonococcus is the suspected organism. Minitipped bacterial culturettes are very useful for collecting sample material for laboratory evaluation in these cases.
Most patients report hyperemia, which may be localized, with irritation and stickiness of one eye followed by bilateral involvement in two to three days. Bacterial conjunctivitis frequently presents nasally initially, and then involves the remaining conjunctival surface. A mucopurulent or purulent discharge usually appears within the fi rst 24 hours, which may lead to some patients reporting that the eyelids are matted shut upon awakening in the morning. The sensation of eyelid stickiness or matting is more common in chronic or severe cases.
• Treatment. Topical antibiotics are the mainstay of bacterial conjunctivitis treatment. Many recent and older antibiotic agents are effective for the treatment of bacterial conjunctivitis. This is important to understand in today’s world of managed care, where formulary restrictions may make it diffi cult or limit the ability to treat with many of the later generation fl uoroquinolone or macrolide agents.
Proper adjunctive treatment of the eyelids is also important in chronic bacterial or lid diseaserelated conjunctivitis. Daily lid hygiene/scrubs should be part of the management plan in these cases and continue on a maintenance basis long term. Lid scrubs with a commercially prepared eyelid cleansing foam or pad product are preferred over baby shampoo for this procedure. Adjunctive treatment with a broad-spectrum oral penicillin or cephalosporin antibiotic, such as amoxicillin/ clavulanate potassium, may be indicated in hyperacute conjunctivitis, chronic conjunctivitis related to lid disease or if associated preseptal cellulitis is suspected. For Neisseria gonorrhoeae-related hyperacute conjunctivitis, one gram of ceftriaxone by IM injection is required.
Proper adjunctive treatment of the eyelids is also important in chronic bacterial or lid diseaserelated conjunctivitis. Daily lid hygiene/scrubs should be part of the management plan in these cases and continue on a maintenance basis long term. Lid scrubs with a commercially prepared eyelid cleansing foam or pad product are preferred over baby shampoo for this procedure. Adjunctive treatment with a broad-spectrum oral penicillin or cephalosporin antibiotic, such as amoxicillin/ clavulanate potassium, may be indicated in hyperacute conjunctivitis, chronic conjunctivitis related to lid disease or if associated preseptal cellulitis is suspected. For Neisseria gonorrhoeae-related hyperacute conjunctivitis, one gram of ceftriaxone by IM injection is required.
EYE
H10.30 Acute Conjunctivitis, Unspecified
H10.429 Chronic Conjunctivitis, Simple
H10.44 Vernal Conjunctivitis
H10.45 Other Chronic Allergic Conjunctivitis
H10.501 Blepharoconjunctivitis, Unspecified, Right Eye
H10.502 Blepharoconjunctivitis, Unspecified, Left Eye
H10.503 Blepharoconjunctivitis, Unspecified, Bilateral
H10.509 Blepharoconjunctivitis, Unspecified
EYE
H10.30 Acute Conjunctivitis, Unspecified
H10.429 Chronic Conjunctivitis, Simple
H10.44 Vernal Conjunctivitis
H10.45 Other Chronic Allergic Conjunctivitis
H10.501 Blepharoconjunctivitis, Unspecified, Right Eye
H10.502 Blepharoconjunctivitis, Unspecified, Left Eye
H10.503 Blepharoconjunctivitis, Unspecified, Bilateral
H10.509 Blepharoconjunctivitis, Unspecified
EAR
H60.391 Infective Otitis Externa, Right Ear
H60.392 Infective Otitis Externa, Left Ear
H60.393 Infective Otitis Externa, Unspecified Ear
H60.399 Infective Otitis Externa, Unspecified Ear
H65.00 Acute Serous Otitis Media, Unspecified Ear
H65.01 Acute Serous Otitis Media, Right Ear
H65.02 Acute Serous Otitis Media, Left Ear
H65.03 Acute Serous Otitis Media, Bilateral
H65.119 Acute Allergic Serous Otitis Media
H65.20 Chronic Serous Otitis Media
H65.21 Chronic Serous Otitis Media, Right Ear
H65.22 Chronic Serous Otitis Media, Left Ear
H65.23 Chronic Serous Otitis Media, Bilateral
H65.90 Other and Unspecified Chronic Nonsuppurative Otitis Media.
Unspecified Ear
H65.91 Nonsuppurative Otitis Media, Right Ear
H65.92 Nonsuppurative Otitis Media, Left Ear
H65.93 Nonsuppurative Otitis Media, Bilateral
H66.90 Otitis Media, Unspecified
H66.91 Otitis Media, Right Ear
H66.92 Otitis Media, Left Ear
H66.93 Otitis Media, Bilateral
H69.80 Dysfunction of Eustachian Tube, Unspecified Ear
H69.81 Dysfunction of Eustachian Tube, Left Ear
H69.82 Dysfunction of Eustachian Tube, Right Ear
H69.83 Dysfunction of Eustachian Tube, Bilateral
H83.01 Labyrinthitis, right Ear
H83.02 Labyrinthitis, Left Ear
H83.03 Labyrinthitis, Bilateral
H83.09 Labyrinthitis, Unspecified
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