Glaucoma secondary to eye trauma, right eye, mild stage

This code signifies elevated intraocular pressure and optic nerve damage in the right eye, resulting from a previous traumatic injury to the eye. The glaucoma is in its early stages, indicating minimal optic nerve damage and visual field loss.

Use this code when documentation clearly indicates a diagnosis of glaucoma in the right eye directly attributable to a past eye trauma, and the ophthalmologist has staged it as mild. Supporting documentation should include a history of ocular trauma, elevated IOP, and evidence of mild glaucomatous changes to the optic nerve head or visual field.

• Ensure the documentation specifies "right eye" and "mild stage" to accurately assign this code.
• Do not use this code for glaucoma due to other secondary causes (e.g., inflammation, drugs) or for primary open-angle glaucoma.
• Always sequence the underlying cause of the trauma (e.g., S05.91XA for unspecified injury of right eye and adnexa) if it is still being treated or is relevant to the current encounter.