Primary open-angle glaucoma, unspecified eye, moderate stage

This code signifies a diagnosis of primary open-angle glaucoma (POAG) where the specific eye affected is not documented, and the disease has progressed to a moderate stage. POAG is a chronic, progressive optic neuropathy characterized by optic nerve damage and visual field loss, typically associated with elevated intraocular pressure. Moderate stage indicates a defined level of visual field impairment according to established glaucoma staging criteria.

Use this code when documentation confirms a diagnosis of primary open-angle glaucoma with moderate visual field defects, but the medical record does not specify whether the right or left eye is affected. This code is appropriate when the physician explicitly states "unspecified eye" or when laterality cannot be determined from the clinical notes.

• Ensure documentation clearly supports "moderate stage" based on visual field testing (e.g., mean deviation, pattern standard deviation) or optic nerve damage.
• Avoid using this code if laterality (right or left eye) is documented; instead, select the more specific H40.1112 (right eye) or H40.1122 (left eye).
• Always query the provider for clarification on laterality if it's missing, as more specific codes are generally preferred for improved data accuracy.