Internal ophthalmoplegia (complete) (total), unspecified eye

This code describes a condition where the intrinsic muscles of the eye, specifically the ciliary body and iris sphincter, are completely paralyzed, leading to a fixed, dilated pupil and loss of accommodation. This paralysis affects the eye's ability to focus on near objects and regulate light entry.

Use this code when documentation indicates a complete or total internal ophthalmoplegia without specifying laterality. This typically occurs due to damage to the parasympathetic innervation of the eye, often from trauma, inflammation, or neurological disorders. Documentation should clearly state "complete" or "total" internal ophthalmoplegia.

• Do not use this code if the ophthalmoplegia is partial or incomplete; instead, consider codes for partial internal ophthalmoplegia (H52.52-).
• Ensure the documentation explicitly states "unspecified eye" or does not specify laterality. If laterality is documented, use the more specific codes (H52.511 for right, H52.512 for left, H52.513 for bilateral).
• Always code any underlying cause or associated condition, such as a neurological disorder or trauma, in addition to this code.