Corneal ulcer with hypopyon, bilateral

This code signifies the presence of an open sore on the cornea, the transparent outer layer of the eye, accompanied by hypopyon, which is a collection of pus or inflammatory cells in the anterior chamber of the eye. This condition affects both eyes, indicating a bilateral presentation of the corneal ulcer with associated intraocular inflammation.

Apply this code when documentation clearly states a diagnosis of corneal ulcer and hypopyon affecting both the right and left eyes. This typically occurs in severe cases of infectious keratitis or other inflammatory conditions where pus accumulates in the anterior chamber. Supporting documentation should include ophthalmological examination findings confirming both the ulceration and the presence of hypopyon in both eyes.

• Ensure documentation specifies "bilateral" involvement; otherwise, use the appropriate unilateral codes (H16.031 or H16.032).
• Always code the underlying cause of the corneal ulcer (e.g., bacterial, fungal, viral infection) first, if known and documented.
• Distinguish from other forms of keratitis without hypopyon; the presence of hypopyon is a key differentiator for this specific code.