Unspecified episcleritis, bilateral

This code signifies inflammation of the episclera, the thin layer of tissue between the conjunctiva and the sclera, affecting both eyes. The specific cause or type of episcleritis is not documented or determined. Patients typically present with bilateral eye redness, mild discomfort, and sometimes tearing.

Use this code when the medical record clearly indicates bilateral episcleritis but lacks further specificity regarding its type (e.g., simple, nodular) or underlying etiology. Documentation should confirm the presence of inflammation in the episcleral tissue of both eyes, without specifying a laterality.

• Ensure documentation explicitly states "bilateral" involvement; otherwise, a unilateral code or unspecified laterality code may be more appropriate.
• Avoid using this code if the type of episcleritis (e.g., simple, nodular) is documented; instead, choose a more specific code from the H15.1 subcategory.
• If an underlying systemic condition is identified as the cause of the episcleritis, code the systemic condition first, followed by this code.