Punctate keratitis, bilateral

This code signifies an inflammatory condition of the cornea characterized by scattered, pinpoint lesions on its surface, affecting both eyes. These lesions represent areas of epithelial cell damage or loss, often causing symptoms like foreign body sensation, photophobia, and blurred vision.

Apply this code when documentation explicitly states "punctate keratitis" and specifies bilateral involvement. This diagnosis is often made via slit-lamp examination, revealing the characteristic corneal findings in both eyes.

• Ensure the medical record clearly indicates bilateral involvement; otherwise, use the appropriate unilateral code (H16.141 or H16.142) or unspecified (H16.149).
• Do not confuse punctate keratitis with other forms of keratitis, such as ulcerative keratitis (H16.0-) or other superficial keratitis (H16.2-).
• Look for an underlying cause if documented, such as viral infection (e.g., herpes simplex keratitis, B00.51) or dry eye syndrome (H04.12-), and code it as a secondary diagnosis.