Primary open-angle glaucoma, right eye, stage unspecified

This code identifies primary open-angle glaucoma affecting the right eye, where the specific stage of the disease has not been documented. This condition is characterized by progressive optic nerve damage and visual field loss, typically associated with elevated intraocular pressure, without an identifiable secondary cause. The "open-angle" refers to the normal appearance of the drainage angle between the iris and cornea.

Use this code when documentation clearly indicates a diagnosis of primary open-angle glaucoma in the patient's right eye, but the physician has not specified the stage (e.g., mild, moderate, severe, or end-stage). This code is appropriate when the medical record confirms the diagnosis and laterality, but lacks the granular detail of staging.

• Always strive for the most specific code available; if a stage is documented, use the appropriate staged code (H40.1111-H40.1114).
• Ensure laterality is clearly documented (right eye, left eye, or bilateral) to avoid unspecified laterality codes.
• Review the entire encounter note for any mention of visual field defects, optic nerve damage severity, or intraocular pressure readings that might imply a specific stage.