Phlyctenular keratoconjunctivitis, unspecified eye

This code describes an inflammatory condition affecting both the cornea and conjunctiva, characterized by the formation of small, nodular lesions called phlyctenules. These lesions are typically a delayed hypersensitivity reaction, often associated with staphylococcal blepharitis or tuberculosis. Patients typically experience symptoms such as irritation, photophobia, tearing, and foreign body sensation.

Use this code when documentation confirms a diagnosis of phlyctenular keratoconjunctivitis without specifying laterality (right, left, or bilateral). This code is appropriate when the physician's notes clearly describe the presence of phlyctenules on the conjunctiva or cornea, along with associated inflammation. It is often used when the exact cause of the hypersensitivity reaction is not yet determined or documented.

• Ensure the documentation explicitly states "phlyctenular keratoconjunctivitis" or describes the characteristic phlyctenules.
• Avoid using this code if laterality is specified; instead, use the more specific codes for right (H16.251), left (H16.252), or bilateral (H16.253) involvement.
• Consider coding any underlying conditions, such as blepharitis (H01.0-) or tuberculosis (A15-A19), as secondary diagnoses if documented.