Unsp lagophthalmos, bilateral, upper and lower eyelids

This code signifies an unstated inability to fully close the eyelids, affecting both the upper and lower lids of both eyes. This condition leaves the ocular surface exposed, potentially leading to dryness, irritation, and corneal damage. The specific cause or type of lagophthalmos is not documented.

Use this code when the medical record clearly indicates lagophthalmos affecting both eyes, involving both upper and lower eyelids, but the physician has not specified the underlying etiology or a more precise type of lagophthalmos. Documentation should explicitly state "bilateral" and "unspecified" or lack further detail regarding the cause.

• Avoid using this code if a more specific type of lagophthalmos (e.g., paralytic, nocturnal) is documented.
• Ensure the documentation clearly specifies involvement of both upper and lower eyelids, as well as bilaterality.
• Consider querying the provider for more specific information if "unspecified" is used but a cause is likely known.