Perforated corneal ulcer, right eye

This code signifies a full-thickness defect in the cornea, specifically the right eye, resulting from the progression of a corneal ulcer. This perforation breaches the corneal layers, potentially leading to iris prolapse, endophthalmitis, or loss of anterior chamber integrity.

Use this code when documentation clearly indicates a perforated corneal ulcer affecting the right eye. This typically occurs in severe cases of infectious keratitis, neurotrophic keratopathy, or autoimmune conditions. Supporting documentation should detail the presence of a corneal perforation and specify the affected eye.

• Ensure laterality is accurately documented and coded; this code is specific to the right eye.
• Always code the underlying cause of the corneal ulcer (e.g., bacterial keratitis, viral keratitis) in addition to the perforation.
• Differentiate from non-perforated corneal ulcers (H16.00-H16.06) and corneal scars (H17.-) which represent different stages or outcomes.