H10.811

🧬 ICD-10-CM H10.811 — Pingueculitis, Right Eye

Overview

ICD-10-CM H10.811 classifies pingueculitis of the right eye — an acute or subacute inflammatory episode superimposed on a pre-existing pinguecula of the bulbar conjunctiva. A pinguecula is a benign, non-neoplastic, yellowish-white elevated deposit on the interpalpebral bulbar conjunctiva (typically on the nasal side, less commonly temporal) composed of degenerated collagen and elastin fibers with calcification. It is strongly associated with chronic ultraviolet light exposure, wind, dust, and dry environments. Pingueculitis occurs when the pinguecula becomes acutely inflamed — manifesting as localized conjunctival injection, chemosis, discomfort, foreign body sensation, and tearing overlying the lesion.

The critical distinction between H10.811 and H11.151 (pinguecula, right eye) is inflammatory status: H10.811 = the pinguecula is actively inflamed; H11.151 = the pinguecula is present but not inflamed. These two codes carry an Excludes1 relationship with each other, meaning they cannot be coded together for the same eye at the same encounter. The clinician’s documentation of inflammation (injection, tenderness, chemosis overlying the lesion) is the determining factor for code selection.

Code Breakdown

The structure of H10.811 follows the ICD-10-CM taxonomy:

Segment	Value	Description
Category	H10	Conjunctivitis
Subcategory	H10.8	Other conjunctivitis
Subgroup	H10.81	Pingueculitis
Laterality	1	Right eye

Full H10.81x Laterality Subcodes

Code	Description
H10.811	Pingueculitis, right eye ← YOU ARE HERE
H10.812	Pingueculitis, left eye
H10.813	Pingueculitis, bilateral
H10.819	Pingueculitis, unspecified eye

Laterality Required — Query When Undocumented

ICD-10-CM guidelines require the most specific code supported by documentation. When laterality is documented in the medical record, H10.819 (unspecified eye) is not appropriate. If the provider documents “pingueculitis” without specifying which eye, query for clarification before defaulting to the unspecified code. For bilateral pingueculitis, use H10.813 — do not report H10.811 and H10.812 simultaneously for the same encounter.

Coding Guidelines

Includes

• Inflamed pinguecula, right eye
• Acute or subacute inflammation of a pinguecula on the right bulbar conjunctiva
• Symptomatic pinguecula with conjunctival injection, chemosis, or discomfort localized to the lesion
• Pinguecula with localized conjunctivitis

Excludes1 — Mutually Exclusive; Cannot Code Together With H10.811

• Pinguecula, right eye (H11.151) — a non-inflamed pinguecula on the same eye cannot be coded alongside H10.811; when inflamed = H10.811 (this code); when not inflamed = H11.151; choose one based on the presence or absence of active inflammation at the time of the encounter
• Keratoconjunctivitis (H16.2-) — Excludes1 at the H10 category level; keratoconjunctivitis is a distinct condition coded from H16.2-; cannot be reported alongside H10.811 for the same condition

Excludes2 — Distinct Conditions; May Be Coded Together When Both Present

• Pseudopterygium (H11.81-) — a fibrovascular adhesion of conjunctiva to the cornea following prior inflammation; distinct from pinguecula; may coexist and be separately coded when both are documented

Pingueculitis Grading — Clinical Context for Documentation

Grade	Description	Typical Code
P0	No pinguecula present	N/A
P1	Mild/moderate pinguecula — flat, yellowish-white lesion, minimally elevated, not inflamed	H11.151 (non-inflamed)
P1 inflamed	Grade P1 lesion with localized injection, irritation, foreign body sensation	H10.811
P2	Severe pinguecula — highly vascularized, elevated, thickened lesion	H11.151 (non-inflamed) or H10.811 (if inflamed)

Code Tree

Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
└── Disorders of conjunctiva (H10-H11)
    ├── Conjunctivitis (H10)
    │   └── Other conjunctivitis (H10.8)
    │       └── Pingueculitis (H10.81)
    │           ├── H10.811 — Pingueculitis, right eye  ← YOU ARE HERE
    │           ├── H10.812 — Pingueculitis, left eye
    │           ├── H10.813 — Pingueculitis, bilateral
    │           └── H10.819 — Pingueculitis, unspecified eye
    │
    └── Other disorders of conjunctiva (H11)
        └── Conjunctival degenerations and deposits (H11.1)
            └── Pinguecula (H11.15)
                ├── H11.151 — Pinguecula, right eye  ← NON-INFLAMED COUNTERPART (Excludes1 with H10.811)
                ├── H11.152 — Pinguecula, left eye
                ├── H11.153 — Pinguecula, bilateral
                └── H11.159 — Pinguecula, unspecified eye

H10.811 vs. H11.151 — The Inflammation Gate

This is the single most important distinction for this code. The Excludes1 between H10.81 (pingueculitis) and H11.15 (pinguecula) means the same eye cannot carry both at the same time. The gate is inflammation:

• Patient presents with symptomatic, red, irritated right nasal conjunctiva overlying a yellowish lesion → H10.811
• Patient presents for routine exam; yellowish lesion noted, no injection, no symptoms from the lesion → H11.151
• Patient had inflamed pinguecula last visit; now quiescent at today’s visit → change to H11.151 for this encounter

Risk Adjustment (HCC)

Hierarchical Condition Category (HCC) status determines impact on risk adjustment scores for Medicare Advantage and ACA plans.

• HCC Status: No — H10.811 does not map to a CMS-HCC v28 category
• RAF Impact: This code does not contribute to the RAF score under the CMS-HCC v28 model
• Clinical Relevance: Pingueculitis does not carry HCC weight. However, recurrent or severe pingueculitis with associated dry eye (H04.121) or ocular surface disease can generate meaningful procedure code revenue (excision, drug therapy). The co-documentation of H04.121 alongside H10.811 is clinically appropriate in many patients and supports broader treatment planning

Inpatient Impact (MS-DRG)

In the inpatient setting, H10.811 influences MS-DRG assignment.

• CC/MCC Status: Non-CC — H10.811 does not carry CC or MCC weight under CMS MS-DRG v42
• Impact: Pingueculitis does not independently drive or influence inpatient admission or DRG assignment under any foreseeable clinical scenario. This code will appear only as an incidental secondary diagnosis if a patient with pingueculitis is admitted for a completely unrelated condition
• POA Indicator: POA = Y for any pre-existing pingueculitis documented at the time of inpatient admission

Common CPT Pairings

Evaluation and Examination

CPT Code	Description	When Used With H10.811
92014	Ophthalmological services; medical examination and evaluation, comprehensive, established patient	Comprehensive eye exam when pingueculitis is identified as part of a broader ocular evaluation
92012	Ophthalmological services; intermediate, established patient	Focused follow-up for established pingueculitis patient on topical therapy
92002	Ophthalmological services; new patient, intermediate	New patient presenting with acute pingueculitis flare
92004	Ophthalmological services; new patient, comprehensive	New patient, pingueculitis as part of comprehensive ocular workup

Procedural Interventions — Excision (Refractory or Cosmetically Indicated)

CPT Code	Description	When Used With H10.811
68110	Excision of lesion, conjunctiva; up to 1 cm	Surgical excision of pinguecula/pingueculitis lesion measuring up to 1 cm when conservative treatment fails or patient requests cosmetic removal; billed per eye
68115	Excision of lesion, conjunctiva; over 1 cm	Excision for larger lesion exceeding 1 cm; per eye; less common for pinguecula
68130	Excision of lesion, conjunctiva, with adjacent sclera	Reserved for lesions with scleral involvement; uncommon for isolated pinguecula
65778	Placement of amniotic membrane on the ocular surface; without sutures	Amniotic membrane application post-excision to reduce recurrence and promote smooth conjunctival healing

Biopsy and Excision — Not Same Day

A biopsy and excision of the same conjunctival lesion are not payable on the same date of service. If the surgical plan is excision, code only the excision (68110 or 68115). If a biopsy is performed first to confirm the diagnosis before excision is scheduled, the biopsy and the subsequent excision may be billed on separate dates.

Topical Therapy — Commonly Associated Drug Billing

Category	Drug Example	Billing Note
Topical NSAID	Ketorolac 0.5% (Acular), bromfenac 0.09% (Prolensa)	Physician-dispensed drops may be billed via HCPCS if applicable; typically outpatient Rx only
Topical corticosteroid	Loteprednol 0.5% (Lotemax), prednisolone 1%	Short-course steroid for acute flare; document duration and taper plan; physician-dispensed billing applies if in-office dispensing occurs
Lubricating drops	OTC artificial tears	Not separately billable; included in E/M service
Vasoconstrictors	Naphazoline/pheniramine (Naphcon-A)	OTC; not separately billable

Clinical Coding Examples

Example 1: Acute Pingueculitis Flare, Right Eye, Established Patient

Scenario: A 48-year-old outdoor worker and known pinguecula patient presents with sudden onset right eye redness, irritation, and tearing for 2 days. Slit lamp examination reveals a Grade P2 elevated nasal pinguecula on the right eye with marked localized injection and chemosis overlying the lesion. Left eye is unremarkable. The physician diagnoses acute pingueculitis, right eye, and prescribes loteprednol 0.5% four times daily for 5 days with lubricating drop supplementation.

Coding:

• Primary: H10.811 — Pingueculitis, right eye
• CPT: 92012 — Ophthalmological services, established patient, intermediate
• Note: H11.151 is NOT coded here — the Excludes1 applies; the lesion is currently inflamed; H10.811 is the correct and only code for the right eye at this encounter.

Example 2: Pingueculitis With Concurrent Dry Eye Syndrome

Scenario: A 62-year-old female with established dry eye syndrome and bilateral pingueculae presents for follow-up. The right pinguecula is acutely inflamed (injection, irritation). The left pinguecula is quiescent. The physician manages both conditions.

Coding:

• Primary: H10.811 — Pingueculitis, right eye (inflamed right pinguecula)
• Secondary: H11.152 — Pinguecula, left eye (non-inflamed left pinguecula — this code is appropriate because the left lesion is NOT inflamed; no Excludes1 conflict arises between H10.811 for one eye and H11.152 for the other eye since they are different lateralities)
• Secondary: H04.123 — Dry eye syndrome, bilateral lacrimal glands
• CPT: 92014 — Comprehensive ophthalmological exam

Note

The Excludes1 between H10.811 and H11.151 applies per eye. Reporting H10.811 for the right eye (inflamed) and H11.152 for the left eye (non-inflamed) is not a violation — they are different codes for different eyes. The mutual exclusivity only applies when coding the same eye as both inflamed and non-inflamed simultaneously.

Example 3: Surgical Excision for Chronic Recurrent Pingueculitis

Scenario: A 55-year-old male with 3 documented recurrences of right eye pingueculitis in the past 12 months presents for surgical excision. The pinguecula is 8 mm in its largest dimension. Surgery is performed with excision of the lesion and bare sclera technique; an amniotic membrane graft is placed to reduce recurrence risk.

Coding:

• Primary: H10.811 — Pingueculitis, right eye — active indication for surgical intervention
• CPT 1: 68110 — Excision of lesion, conjunctiva, up to 1 cm (8 mm lesion = less than 1 cm)
• CPT 2: 65778 — Placement of amniotic membrane, without sutures — if sutured: 65779
• Note: Modifier -25 applies to any same-day office visit billed alongside the excision only if a separately identifiable E/M service (beyond the pre-operative assessment for the procedure) is performed and documented.

Example 4: Ruling Out H10.811 — Using H11.151 Instead

Scenario: A 40-year-old male presents for a routine annual eye exam. Slit lamp reveals a small, yellowish, flat lesion on the nasal right bulbar conjunctiva consistent with a Grade P1 pinguecula. The patient is asymptomatic and denies any eye redness or irritation. The physician documents “pinguecula, right eye — no active inflammation.”

Coding:

• Do NOT use H10.811 here. The lesion is documented as non-inflamed. The correct code is H11.151 — Pinguecula, right eye. H10.811 requires documented inflammation. When the clinician notes the lesion is quiescent, asymptomatic, and non-inflamed, H11.151 is the appropriate code and the Excludes1 directs you away from H10.811 for the same encounter and same eye.

Revenue Cycle Considerations

• wRVU: Not applicable — ICD-10-CM codes do not carry wRVUs; associated CPT codes (92012, 68110) carry the wRVU value for the encounter
• Assistant Payable: Not applicable
• Denial Risk: Low for medical management; Moderate for surgical cases. Topical steroid and NSAID therapy for pingueculitis is a covered conservative treatment with low denial risk when diagnosis is clearly documented. Surgical excision (68110, 68115) carries a moderate denial risk — payers may request chart documentation demonstrating failed conservative management or significant functional impairment (decreased vision, inability to wear contact lens, chronic recurrence with documented visits) before approving excision. Purely cosmetic excision is non-covered by most payers including Medicare
• Cosmetic vs. Medical Necessity: Excision of pinguecula/pingueculitis (68110, 68115) is covered when medically necessary (recurrent inflammation, contact lens intolerance, significant ocular surface compromise). It is not covered when performed solely for cosmetic reasons. Documentation must clearly establish functional impairment or chronic symptomatic disease. A single asymptomatic lesion with a patient request for removal does not meet medical necessity criteria
• H10.811 vs. H11.151 on Claim Review: Payers performing claim history review may flag a pattern of alternating H10.811 and H11.151 on the same eye across encounters — this is clinically normal (flare → remission → flare) and is consistent with the natural course of pingueculitis. Ensure documentation at each visit clearly describes the current inflammatory status of the lesion to support whichever code is assigned

Related Codes

• H11.151: Pinguecula, right eye — non-inflamed counterpart; Excludes1 with H10.811 for the same eye
• H11.152: Pinguecula, left eye — non-inflamed, left side
• H11.153: Pinguecula, bilateral — non-inflamed, bilateral
• H10.812: Pingueculitis, left eye
• H10.813: Pingueculitis, bilateral
• H10.819: Pingueculitis, unspecified eye — avoid when laterality is documented
• H11.021-H11.029: Pterygium — a distinct but related condition involving fibrovascular growth onto the cornea; do not confuse with pinguecula (which does not cross the limbus)
• H11.811: Pseudopterygium of conjunctiva, right eye — post-inflammatory fibrovascular adhesion; distinct from true pterygium and from pinguecula
• H04.121: Dry eye syndrome, right lacrimal gland — frequently co-documented with pingueculitis; may be separately coded when both are diagnosed

Clinical Management Notes

Management of H10.811 is conservative in the vast majority of cases:

• Acute flare management: Topical NSAIDs (ketorolac, bromfenac) and/or short-course topical corticosteroids (loteprednol 0.5%); typically 5-10 day steroid taper; lubricating preservative-free drops for surface comfort
• UV protection counseling: Wraparound sunglasses with UV protection, wide-brimmed hats; address occupational UV exposure when applicable
• Dry environment mitigation: Humidifiers, reducing screen time, avoiding fans directed at the eyes
• Surgical management (68110, 68115): Reserved for chronic/recurrent episodes unresponsive to medical therapy, contact lens intolerance from the lesion, or significant cosmetic concern with documented functional impact; amniotic membrane graft (65778) post-excision reduces recurrence risk
• Patient education: Distinguish pinguecula (cannot spread to cornea) from pterygium (can); reassure patient about benign nature; emphasize UV protection as primary prevention for both recurrence and progression

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^{ICD-10-CM Official Guidelines for Coding and Reporting FY2025 CMS ICD-10-CM Tabular List FY2025 CMS MS-DRG Grouper v42 (FY2025) CMS-HCC Risk Adjustment Model v28 (2024) AAPC ICD-10-CM Code Reference — H10.811, H10.81, H11.151 ECG Waves ICD-10 Reference — H10.811 Pingueculitis, Right Eye (2024) GenHealth.ai ICD-10-CM Code Browser — H10.811 StatPearls — Pinguecula (NBK558965, 2023) EyeMed Management — Coding Tips for Common Ophthalmology Services: Pinguecula Excision (2020) AMA CPT 2025 Professional Edition Omni Eye Services ICD-10 Quick Reference Guide}