Open angle with borderline findings, low risk, bilateral

This code signifies a form of glaucoma characterized by an open anterior chamber angle, but with optic nerve or visual field findings that are considered borderline or suspicious for glaucoma, yet are currently at a low risk of progression. It indicates that both eyes exhibit these characteristics.

Apply this code when a patient presents with bilateral open-angle findings, where diagnostic tests (e.g., OCT, visual field) show subtle or early changes suggestive of glaucoma, but not definitive enough for a confirmed diagnosis of primary open-angle glaucoma. Documentation should clearly state "borderline findings," "low risk," or "suspect glaucoma" affecting both eyes.

• Ensure documentation specifies "bilateral" involvement; otherwise, use the appropriate unilateral code.
• Distinguish from codes for confirmed primary open-angle glaucoma (H40.1x) or ocular hypertension (H40.05x).
• This code often precedes more definitive glaucoma diagnoses if the condition progresses.