Coding Dry Eye

Ocular findings:

• Tear film insufficiency (375.15) -- test show decreased TF; for punctal plugs diagnosis
• Keratoconjunctivitis sicca, not specified as Sjogren's (370.33) -- observation of "inflammation of the conjunctiva and cornea, characterized by "horny"-looking tissue and excess blood in these areas"
• Punctate keratitis (370.21)
• Exposure keratitis (370.34)
• Sjogren's syndrome (710.2)

Patient symptoms:

• Eye pain (379.91) -- may be used for all levels of eye discomfort, e.g. burning/stinging
• Redness of eyes (379.93) -- r/o episcleritis (379.01) and scleritis (379.00)
• Epiphora (375.20) -- dry eye due to reflex tearing

Procedure diagnastic codes:

• External ocular photography (92285) -- photos need to document the efficacy of treatment or the progression of the disease, and not just enhance the medical record or billable procedures
• Bandage contact lenses (92070) -- covers fitting and supply of lens