Find comprehensive information on ptosis diagnosis, including clinical documentation tips, medical coding guidelines (ICD-10-CM: H02.40, H02.41-H02.43), and healthcare best practices for managing blepharoptosis, eyelid drooping, acquired ptosis, and congenital ptosis. Learn about the different types of ptosis, including unilateral and bilateral ptosis, and understand the appropriate medical terminology for accurate diagnosis and billing. Explore resources for healthcare professionals related to ptosis evaluation, treatment options, and patient care.
Also known as
Ptosis of eyelid
Covers various types of acquired ptosis, including neurogenic and myogenic.
Congenital ptosis
Identifies ptosis present from birth.
Myasthenia gravis
Autoimmune neuromuscular disorder that can cause ptosis as a symptom.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the ptosis congenital?
Yes
Is it due to birth trauma?
No
Is it neurogenic?
When to use each related code
| Description |
|---|
| Drooping upper eyelid |
| Aponeurotic ptosis |
| Mechanical ptosis |
Incorrectly coding laterality (right, left, bilateral) for ptosis can lead to claim denials or inaccurate reimbursement.
Using unspecified ptosis codes when a more specific diagnosis is documented impacts data quality and reimbursement.
Failing to distinguish between congenital and acquired ptosis can lead to coding errors and affect quality reporting.
Patient presents with ptosis, or drooping eyelid, affecting the rightleft (specify) upper eyelid. Onset was (gradualacute; specify) beginning approximately (duration) ago. Associated symptoms include (diplopia, blurred vision, eye strain, headache, facial weakness; specify if present or absent). Patient denies (pain, trauma, recent illness, neurological symptoms; specify if applicable). Medical history includes (relevant conditions such as myasthenia gravis, Horner syndrome, stroke, diabetes, thyroid disorders, Bell's palsy; specify if present or absent). Family history is (positive, negative) for ptosis or other neuromuscular conditions. Physical examination reveals (mild, moderate, severe) ptosis with (complete, incomplete) closure of the affected eyelid. Margin reflex distance (MRD1, MRD2) measured (record measurements). Levator function assessed as (good, fair, poor) with (number) millimeters of excursion. Extraocular movements are (intact, restricted; specify if applicable). Pupillary examination reveals (equal, unequal) pupils with (normal, abnormal) reaction to light and accommodation. Differential diagnosis includes (myogenic ptosis, neurogenic ptosis, aponeurotic ptosis, mechanical ptosis; specify based on clinical findings). Assessment: Ptosis of the (rightleft) upper eyelid, likely (etiology; e.g., congenital, acquired, involutional). Plan: (Observation, further investigation with neurologyophthalmology consult, imaging studies such as CT or MRI of the brainorbit, tensilon test if myasthenia gravis suspected; specify planned course of action). Patient education provided regarding the condition, its potential causes, and treatment options. Follow-up appointment scheduled for (datetime). ICD-10 code (H02.401, H02.402, H02.403, etc.; specify based on laterality) assigned.