Blepharophimosis unspecified eye, unspecified lid

This code describes a congenital condition characterized by abnormally small palpebral fissures, which are the openings between the eyelids. It results in a narrowed appearance of the eyes due to short horizontal and vertical lid dimensions. This specific code is used when the affected eye and the specific eyelid (upper or lower) are not documented.

Use this code when the medical record clearly indicates blepharophimosis but lacks specificity regarding which eye (right, left, or bilateral) is affected, and does not differentiate between upper or lower lid involvement. Documentation supporting its use would include a diagnosis of blepharophimosis without further detail.

• Avoid using this code if the laterality (right, left, bilateral) or specific lid involvement is documented; instead, choose a more specific code from the H02.52 subcategory.
• This code is for the congenital form of blepharophimosis; do not use it for acquired conditions affecting eyelid size.
• Always query the provider for more specific documentation regarding laterality and lid involvement to allow for more precise coding.