Scleromalacia perforans, bilateral

This code signifies a severe, destructive form of scleritis characterized by thinning and necrosis of the sclera, often leading to perforation, affecting both eyes. It is typically associated with systemic autoimmune diseases like rheumatoid arthritis. The condition can cause significant pain and vision loss due to exposure of the underlying uvea.

Use this code when documentation clearly indicates scleromalacia perforans affecting both eyes. This diagnosis is usually made by an ophthalmologist based on slit-lamp examination revealing areas of scleral thinning, necrosis, and potential uveal prolapse. Supporting documentation should detail the bilateral involvement and the specific characteristics of scleromalacia.

• Ensure the documentation explicitly states "bilateral" involvement; otherwise, a unilateral code may be more appropriate.
• Always code the underlying systemic disease (e.g., rheumatoid arthritis) first, as scleromalacia perforans is often a manifestation of such conditions.
• Differentiate from other forms of scleritis (e.g., anterior, posterior, nodular) which have distinct ICD-10-CM codes.