Primary hypotony of eye, bilateral

This code describes a condition where both eyes have abnormally low intraocular pressure (IOP) without an identifiable secondary cause such as trauma, surgery, or inflammation. This primary hypotony can lead to visual impairment and other ocular complications if left untreated.

Apply this code when documentation clearly indicates idiopathic or primary hypotony affecting both eyes. The physician's notes should specify the absence of a secondary cause and confirm the bilateral involvement. This code is appropriate when the low IOP is the primary diagnosis or a significant co-morbidity.

• Ensure the documentation explicitly states "bilateral" involvement and "primary" or "idiopathic" hypotony.
• Do not use this code if a secondary cause for the hypotony (e.g., post-surgical, traumatic) is identified; instead, code the underlying cause.
• Verify laterality carefully; separate codes exist for unilateral primary hypotony.