Congenital ptosis

This code represents a drooping of the upper eyelid that is present at birth. It results from a developmental abnormality of the levator palpebrae superioris muscle or its innervation, leading to an inability to fully elevate the eyelid. The condition can affect one or both eyes and may range from mild to severe, potentially obstructing vision.

Use this code when documentation clearly indicates a congenital origin for eyelid ptosis. This diagnosis is typically made in infancy or early childhood. Supporting documentation should include physician notes detailing the onset of ptosis at birth or shortly thereafter, often noting the absence of trauma or other acquired causes.

• Differentiate from acquired ptosis (H02.4x) which develops later in life due to various causes.
• Specify laterality if documented (e.g., Q10.01 for right eye, Q10.02 for left eye, Q10.03 for bilateral).
• Do not use this code for pseudoptosis, which is an apparent drooping due to other conditions like microphthalmos or enophthalmos.