Visual discomfort, bilateral

This code signifies a patient experiencing unpleasant or painful visual sensations affecting both eyes. It describes a subjective symptom of visual distress, not a specific disease, that can manifest as eye strain, photophobia, or general ocular discomfort.

Apply this code when documentation indicates a patient reports bilateral visual discomfort without a more specific underlying diagnosis yet established or when the discomfort is the primary reason for the encounter. Supporting documentation should clearly state the bilateral nature of the visual distress.

• Do not use this code if a more specific diagnosis for the visual discomfort (e.g., asthenopia due to refractive error, photophobia due to uveitis) is identified.
• Consider sequencing this code after any underlying causative condition if known and treated during the same encounter.
• Ensure the medical record explicitly states "bilateral" or "both eyes" to support the laterality.