Hyphema, unspecified eye

This code represents the presence of blood in the anterior chamber of the eye, specifically when the affected eye is not documented or is unknown. Hyphema is typically a consequence of trauma but can also arise spontaneously from underlying conditions.

Assign this code when documentation clearly indicates hyphema but does not specify whether it affects the right, left, or both eyes. This code is appropriate for initial encounters or follow-up care where laterality remains unaddressed.

• Always query the provider for laterality if not documented to allow for a more specific code assignment (H21.01, H21.02, H21.03).
• Do not use this code if the documentation specifies the affected eye(s).
• Code any associated trauma or underlying systemic condition as a primary or secondary diagnosis, as appropriate.