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H04.123

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H04.123 — Dry eye syndrome of bilateral lacrimal glands

Short definition

H04.123 identifies dry eye syndrome involving both lacrimal glands, meaning reduced or dysfunctional tear production in both eyes, resulting in bilateral ocular surface dryness, discomfort, and potential visual disturbance.

Long clinical definition

Dry eye syndrome (DES), also called tear film insufficiency, is a multifactorial disease of the tears and ocular surface characterized by loss of homeostasis of the tear film and accompanied by ocular symptoms such as burning, grittiness, fluctuating vision, and foreign body sensation. H04.123 is used when:

  • The condition affects both eyes (OU).
  • There is documented abnormal tear quantity and/or quality (e.g., reduced Schirmer test, reduced tear break-up time, meibomian gland dysfunction).
  • Symptoms are persistent or recurrent enough to require medical therapy (artificial tears, anti-inflammatory drops, punctal plugs, etc.).

The “of bilateral lacrimal glands” wording indicates that both lacrimal glands are contributing to inadequate tear film, either through reduced aqueous production, altered composition, or both. Etiologies include age-related lacrimal hyposecretion, systemic autoimmune disease (e.g., Sjögren, rheumatoid arthritis), medication-related dryness, environmental factors, and eyelid or meibomian gland dysfunction.

Code tree context — H04.1 Dry eye and related disorders

H04 Disorders of lacrimal system

  • H04.0 Dacryoadenitis
  • H04.1 Other disorders of lacrimal gland
    • H04.10 Unspecified disorder of lacrimal gland
    • H04.11 Lacrimal gland dysfunction
    • H04.12 Dry eye syndrome (non-billable header)
      • H04.121 Dry eye syndrome of right lacrimal gland
      • H04.122 Dry eye syndrome of left lacrimal gland
      • H04.123 Dry eye syndrome of bilateral lacrimal glands ← THIS NOTE
      • H04.129 Dry eye syndrome of unspecified lacrimal gland
    • H04.13 Lacrimal cyst (with laterality codes)
    • H04.14 Primary lacrimal gland atrophy
    • H04.15 Secondary lacrimal gland atrophy

Key rule

Do not use H04.12 (3-character header) alone — always choose a laterality-specific child code such as H04.123 when documentation supports bilateral disease.

Includes and excludes

Includes (when bilateral)

H04.123 is appropriate when documentation states:

  • “Dry eye syndrome OU” or “bilateral dry eye.”
  • “Aqueous tear deficiency OU” with decreased Schirmer test in both eyes.
  • “keratoconjunctivitis sicca OU” when non-Sjögren or unspecified systemic association.
  • “Chronic bilateral tear film insufficiency” due to lacrimal gland hypofunction.

Common synonyms aligned with H04.123:

  • Bilateral dry eye syndrome.
  • Bilateral tear film insufficiency.
  • Bilateral lacrimal hyposecretion.
  • Non-Sjögren’s KCS OU when documented as “dry eye syndrome.”

Excludes (conceptual)

Conditions that should be coded separately, not as H04.123 alone:

  • Sjögren syndrome with keratoconjunctivitis sicca

    • Use M35.01 (Sjögren syndrome with keratoconjunctivitis sicca) plus H04.123 if the ophthalmologist documents the ocular manifestation separately. Sjögren drives systemic risk; H04.123 captures ocular surface status.

  • Other lacrimal disorders

    • H04.0x — Dacryoadenitis (infectious/inflammatory lacrimal gland swelling).
    • H04.2x-H04.4x — Lacrimal drainage system disease (epiphora, stenosis, dacryocystitis).

  • Purely evaporative dry eye without lacrimal insufficiency

    • When the provider documents only meibomian gland dysfunction or blepharitis without lacrimal hyposecretion, some practices prefer H02.88x or blepharitis codes plus symptom codes (e.g., H57.1) rather than H04.123. Follow provider’s documentation of mechanism.

  • Medication side-effect dryness only

    • If dry eye is transient and clearly attributable to a short-term drug side effect, some practices code the adverse effect as primary and may omit H04.123 unless chronic DES persists.

Typical clinical context

Symptoms

  • Burning, stinging, grittiness OU.
  • Foreign body sensation OU.
  • Blurred or fluctuating vision that improves with blinking or artificial tears.
  • photophobia or discomfort with computer use and prolonged reading.

Exam findings

  • Reduced tear meniscus height OU.
  • Shortened tear break-up time (TBUT).
  • Punctate epithelial erosions (PEE) on the cornea or conjunctiva (fluorescein or lissamine staining).
  • Decreased Schirmer test results OU.
  • Filamentary keratitis in more severe cases.
  • Conjunctival hyperemia and lid margin changes if meibomian disease coexists.

Common etiologies

  • Age-related lacrimal gland hypofunction.
  • Autoimmune disease (e.g., Sjögren, rheumatoid arthritis, lupus).
  • Post-LASIK or other corneal refractive surgery.
  • Chronic contact lens wear.
  • Environmental (low humidity, high screen time).
  • Medications (antihistamines, anticholinergics, antidepressants, isotretinoin).
  • Hormonal influences (especially post-menopausal).

Relationship to CPT, wRVU, and procedures

H04.123 frequently supports:

  • Eye exam codes

    • 92002 / 92004 — New patient, intermediate/comprehensive ophthalmological services.
    • 92012 / 92014 — Established patient, intermediate/comprehensive.
    • 9920x / 9921x — Standard E/M visits when used instead of 92xxx eye codes.

  • Ocular surface diagnostics

    • 92285 — External ocular photography with interpretation and report (documenting corneal staining, conjunctival changes, lid margin, meibomian glands).
    • 76514 — Pachymetry (less common purely for DES).
    • 83861 (HCPCS, tear osmolarity) when applicable and covered.

  • Punctal occlusion procedures

    • 68760 — Closure of lacrimal punctum; by thermocautery, ligation, or laser surgery (permanent).
    • 68761 — Closure of lacrimal punctum; by plug, each (punctal plugs for tear retention).

  • Other therapeutic interventions

    • Prescription topical anti-inflammatories (cyclosporine, lifitegrast) — E/M only.
    • Scleral lenses or PROSE devices — separate HCPCS and fitting codes, may use H04.123 as supporting diagnosis.

wRVU

  • H04.123 itself has no wRVUs.
  • wRVUs come from CPT codes above, e.g.:
    • 92014 ~1.5 wRVU range.
    • 68761 ~0.7-0.9 wRVU per punctum (varies by year).

HCC / risk adjustment

  • H04.123 does not map to any CMS-HCC.
  • It is not a CC or MCC in MS-DRG logic.
  • Risk impact comes from associated systemic diagnoses:
    • M35.01 — Sjögren syndrome with keratoconjunctivitis sicca.
    • M05.x / M06.x — Rheumatoid arthritis.
    • E11.x — Diabetes mellitus.

Note

Ensure those systemic conditions are coded separately when clearly documented, especially in MA/RAF contexts.

MS-DRG considerations

  • H04.123 is an outpatient diagnosis in nearly all cases.
  • If present on an inpatient record, it is a non-CC/MCC secondary diagnosis, not affecting DRG assignment.
  • In the rare case of an inpatient ophthalmology admission where dry eye is principal (for example, in complex autoimmune conditions with severe ocular surface compromise), H04.123 would fall under MDC 02 (eye) and drive DRGs 124-126 based on presence/absence of CC/MCC — but this is extremely uncommon.

Coding guidelines and laterality

Laterality

  • OU (both eyes) documented → H04.123.
  • OD only → H04.121 (right lacrimal gland).
  • OS only → H04.122 (left lacrimal gland).
  • Eye not specified → H04.129 (unspecified lacrimal gland).

Never code H04.12 alone; always choose the 6-character laterality-specific child code.

When not to use H04.123

  • If documentation only says “dryness” or “burning” without a formal DES diagnosis, consider symptom codes like:
    • H57.10 — Ocular pain, unspecified.
    • H57.9 — Unspecified disorder of eye and adnexa.
  • If the primary problem is blepharitis or meibomian gland dysfunction without aqueous deficiency, consider:
    • H01.001-H01.009 — Blepharitis codes.
    • H02.88x — Other specified disorders of eyelid.

Common coding scenarios

Example 1 — Bilateral age-related dry eye

Scenario
68-year-old woman with burning and foreign body sensation OU, worse with reading and computer work. Exam: low tear meniscus OU, TBUT < 5 seconds OU, mild PEE OU. No systemic autoimmune disease. Diagnosis: “Age-related dry eye syndrome OU.”

ICD-10-CM

  • H04.123 — Dry eye syndrome of bilateral lacrimal glands.

CPT

  • 92014 — Comprehensive eye exam (established).
  • 92285 — External ocular photography (if documented).

Example 2 — Sjögren syndrome with bilateral dry eye

Scenario
55-year-old woman with known Sjögren syndrome presents for ocular surface evaluation. Severe dryness OU, Schirmer < 5 mm OU, diffuse corneal staining OU. Rheumatology notes confirm M35.01.

ICD-10-CM

  • M35.01 — Sjögren syndrome with keratoconjunctivitis sicca.
  • H04.123 — Dry eye syndrome of bilateral lacrimal glands.

CPT

  • 92014 — Comprehensive eye exam.
  • 92285 — External ocular photography.
  • 68761-RT, 68761-LT — Punctal plugs placed in both lower puncta.

Coding note
M35.01 is the systemic driver and may map to HCC; H04.123 captures ocular surface status and supports punctal plug procedures.

Example 3 — Bilateral dry eye after LASIK

Scenario
40-year-old status post bilateral LASIK 6 months ago with persistent dryness OU despite OTC artificial tears. Exam: mild PEE OU, TBUT 6 seconds OU, normal retina.

ICD-10-CM

  • H04.123 — Dry eye syndrome of bilateral lacrimal glands.
  • Z98.890 — Other specified postprocedural states (history of LASIK).

CPT

  • 92012 — Intermediate eye exam.
  • 92285 — External ocular photography (if documenting corneal staining before changing therapy).

Example 4 — Unilateral vs. bilateral coding

Scenario
Provider initially documents “dry eye OU,” but detailed slit-lamp findings show only left eye is clinically significant; right eye is essentially normal. Provider’s final assessment: “Clinically significant dry eye OS.”

ICD-10-CM

  • H04.122 — Dry eye syndrome of left lacrimal gland.

Coding note
Respect the provider’s final assessment. If they specify only one eye as truly affected, code unilateral rather than bilateral.

Example 5 — Bilateral dry eye with punctal plugs

Scenario
72-year-old with chronic DES OU, inadequately controlled with tears and cyclosporine. Ophthalmologist places temporary collagen plugs in both lower puncta and plans permanent silicone plugs if successful.

ICD-10-CM

  • H04.123 — Dry eye syndrome of bilateral lacrimal glands.

CPT

  • 68761-RT — Closure of lacrimal punctum by plug, right lower punctum.
  • 68761-LT — Closure of lacrimal punctum by plug, left lower punctum.

Coding note
Use separate line items with RT/LT or a single line with -50 for bilateral, depending on payer. H04.123 supports medical necessity for punctal occlusion.

Documentation pearls

  • Document laterality clearly (OD/OS/OU) and translate to specific ICD-10 codes.
  • Include objective findings (Schirmer, TBUT, staining patterns) where available — especially when justifying procedures like punctal plugs or expensive prescription drops.
  • If DES is secondary to systemic disease (e.g., Sjögren, RA, graft-versus-host), document and code the systemic condition explicitly.
  • For Medicare and many commercial payers, persistent symptoms and failed conservative management strengthen the case for punctal occlusion and advanced therapies.

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