Birth injury to eye

This code signifies an ocular injury sustained by a neonate during the birth process. This can include conditions such as subconjunctival hemorrhage, corneal abrasion, retinal hemorrhage, or other structural damage to the eye directly attributable to delivery. These injuries are typically identified shortly after birth.

Apply this code when documentation clearly indicates an eye injury in a newborn that occurred during labor or delivery. Supporting documentation would include physician notes detailing the type of ocular injury, its presence at birth or shortly thereafter, and a clear link to the birth event.

• Always specify the laterality of the eye injury (e.g., right, left, bilateral, or unspecified).
• Code the specific type of eye injury first, if a more detailed code is available (e.g., H11.3 for subconjunctival hemorrhage), and then use this code as a secondary diagnosis to indicate the birth injury etiology.
• Ensure the medical record differentiates between birth-related trauma and congenital anomalies or other acquired eye conditions.