Phlyctenular keratoconjunctivitis, bilateral

This code describes an inflammatory condition affecting both the cornea and conjunctiva, characterized by the formation of small, grayish-white nodules (phlyctenules). These lesions are typically a delayed hypersensitivity reaction, often associated with staphylococcal blepharitis or tuberculosis.

Use this code when documentation clearly indicates phlyctenular keratoconjunctivitis affecting both eyes. This diagnosis is typically made based on slit lamp examination revealing characteristic phlyctenules on the conjunctiva or cornea, along with symptoms such as photophobia, tearing, and irritation.

• Ensure laterality is explicitly documented as bilateral; otherwise, use the appropriate unilateral code.
• Investigate underlying causes (e.g., tuberculosis, staphylococcal infection) and code them additionally if confirmed.
• Differentiate from other forms of keratoconjunctivitis (e.g., allergic, viral) which have distinct ICD-10-CM codes.