Internal ophthalmoplegia (complete) (total), bilateral

This code describes a complete paralysis of the intrinsic muscles of both eyes, specifically the ciliary body and iris. This results in bilateral mydriasis (dilated pupils) and cycloplegia (paralysis of accommodation), leading to blurred vision, particularly for near objects.

Assign this code when documentation clearly indicates a total internal ophthalmoplegia affecting both eyes. This typically presents with fixed, dilated pupils and an inability to focus at varying distances due to ciliary muscle paralysis. Supporting documentation should specify the bilateral nature and completeness of the internal ophthalmoplegia.

• Ensure the documentation explicitly states "complete" or "total" internal ophthalmoplegia; partial involvement would require a different code.
• Verify the laterality is clearly documented as "bilateral" to support this specific code.
• Distinguish from external ophthalmoplegia, which involves the extraocular muscles and affects eye movement.