AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2024 Issue 3; Ask the Editor

Keratoconjunctivitis Sicca

A patient presents for the insertion of Prokera® bilaterally due to a diagnosis of keratoconjunctivitis sicca oculus uterque (OU). The Index lists the default code as M35.0, Sjogren syndrome, with Sjogren’s in parenthesis indicating it is a nonessential modifier. However, “not Sjogren’s” is indexed directly underneath, which directs to category H16.22-, Keratoconjunctivitis sicca, not specified as Sjogren’s. What is the correct code assignment when the provider documents “keratoconjunctivitis sicca” without mention of Sjogren’s syndrome? ...

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