What is the ICD-10 (International Classification of Diseases, 10th Revision) code for an inner eyelid abrasion?

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ICD-10 Code for Inner Eyelid Abrasion

The appropriate ICD-10 code for an inner eyelid abrasion is S00.20- (Contusion of eyelid and periocular area), which requires additional character specification for laterality.

Coding Details

The inner eyelid abrasion is coded using the following approach:

Primary Code Selection

  • S00.20- is the base code for contusion of eyelid and periocular area
  • This requires a 6th character to specify laterality:
    • S00.201- for right eye
    • S00.202- for left eye
    • S00.209- for unspecified eye

Additional Character Required

  • A 7th character is needed to indicate the encounter type:
    • A for initial encounter
    • D for subsequent encounter
    • S for sequela

Complete Code Examples

  • S00.201A: Contusion of right eyelid and periocular area, initial encounter
  • S00.202A: Contusion of left eyelid and periocular area, initial encounter

Coding Considerations

Anatomical Specificity

  • The inner eyelid refers to the conjunctival surface (palpebral conjunctiva) of the eyelid 1
  • Abrasions to this area are classified as contusions in the ICD-10 coding system

Alternative Codes to Consider

If the abrasion involves the conjunctiva specifically, consider:

  • S05.0- (Injury of conjunctiva and corneal abrasion without foreign body)
    • Requires similar laterality and encounter specification

Documentation Requirements

For accurate coding, document:

  1. Specific location (inner eyelid/palpebral conjunctiva)
  2. Laterality (right, left, or bilateral)
  3. Encounter type (initial, subsequent, follow-up)
  4. Any associated conditions (infection, foreign body, etc.)

Clinical Context

Inner eyelid abrasions may present with:

  • Foreign body sensation
  • Pain or discomfort
  • Tearing
  • Redness
  • Photophobia 2

Proper documentation of these symptoms helps support the selected diagnosis code and medical necessity for treatment.

Coding Pitfalls to Avoid

  • Do not confuse with H10.- codes (conjunctivitis), which represent inflammatory conditions rather than traumatic injuries
  • Avoid using S05.0- codes unless the conjunctiva is specifically documented as injured
  • Remember that the 7th character is mandatory for codes in the S00-T88 range

Proper coding ensures accurate medical records, appropriate reimbursement, and valuable data for research and surveillance of ocular injuries.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Management of corneal abrasions.

American family physician, 2004

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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