Glaucoma secondary to eye inflam, bilateral, moderate stage

This code signifies glaucoma that has developed as a direct consequence of inflammation within both eyes, and the disease has progressed to a moderate stage. This secondary glaucoma is characterized by increased intraocular pressure leading to optic nerve damage and visual field loss, directly attributable to an underlying inflammatory process.

Use this code when documentation clearly indicates bilateral glaucoma resulting from an inflammatory condition (e.g., uveitis, iritis) and the ophthalmologist has staged the glaucoma as moderate. Supporting documentation should include a diagnosis of secondary glaucoma, the inflammatory etiology, and an assessment of the disease stage based on visual field defects and optic nerve damage.

• Ensure the documentation explicitly links the glaucoma to an inflammatory cause; otherwise, a primary glaucoma code may be more appropriate.
• Verify that the laterality is bilateral and the stage is specifically documented as moderate. Different codes exist for other stages (mild, severe, indeterminate).
• Always code the underlying inflammatory condition first, as it is the primary cause of the secondary glaucoma.