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H11.002

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🧬 ICD-10-CM H11.002 — Unspecified Pterygium of Left Eye

Quick Reference

Code: H11.002 | Billable: Yes | Chapter: 7 — Eye and Adnexa | HCC: No | Laterality: Left eye | Type: Unspecified (specific pterygium subtype not documented)

Description

ICD-10-CM H11.002 identifies a pterygium of the left eye where the specific subtype has not been documented by the treating provider. A pterygium (from the Greek pterygion, meaning “little wing”) is a fibrovascular growth of bulbar conjunctival tissue that encroaches onto the corneal surface — most commonly arising from the nasal limbus and extending across the cornea in a wing-shaped pattern.2 It is one of the most common ocular surface conditions in ophthalmology and optometry, particularly in patients with high cumulative UV light exposure, and bilateral presentation is frequently encountered in outdoor workers and equatorial populations.2

H11.002 is assigned when the pterygium of the left eye is documented but the specific type or clinical subtype is not stated in the provider’s note — meaning the record does not describe the growth as central, double, amyloid, stationary peripheral, progressive peripheral, or recurrent. When a specific type is documented, a more precise code from the H11.0 subcategory should always be selected. As a profee coder, review the full encounter note, slit lamp findings, topography results, and any procedural documentation before defaulting to the unspecified code — pterygium subtype is often determinable from the clinical description even when not explicitly labeled.3

Pterygium vs. Pseudopterygium — Critical Coding Distinction

FeatureTrue Pterygium (H11.002)Pseudopterygium (H11.812)
OriginPrimary fibrovascular growth from bulbar conjunctiva crossing the limbusSecondary adhesion of conjunctiva to cornea following trauma, chemical burn, or inflammatory scarring
Limbal attachmentPresent — pterygium has a true limbal attachmentAbsent — a probe can be passed beneath pseudopterygium at the limbus
ProgressionGrows toward corneal center; may be stationary or progressiveDoes not grow in the same manner; represents cicatricial adhesion
UV associationStrong association with chronic UV exposureNo UV association — associated with prior ocular surface injury
RecurrenceCommon after surgery (~30-80% without graft; ~5-15% with graft)14Less typical; depends on underlying cause
ICD-10-CMH11.00x-H11.06xH11.811-H11.819
Excludes1 relationshipH11.0x Excludes1 H11.81-Mutually exclusive at code level

These are Excludes1 to each other — a true pterygium and a pseudopterygium cannot be coded simultaneously for the same eye at the same encounter. The distinction is clinical and must be documented by the provider — a probe test at the limbus is the definitive bedside test.3

Code Structure & Hierarchy

Code Tree

  • Chapter: 7 — Diseases of the Eye and Adnexa (H00-H59)
  • Block: H10-H11 — Disorders of Conjunctiva
    • H11 — Other disorders of conjunctiva ← this category
      • H11.0 — Pterygium of eye ← this subcategory
      • H11.81 — Pseudopterygium of conjunctiva ← Excludes1 to all H11.0x

H11.002 vs. Sibling Left-Eye Codes — Type Specificity Decision Table

CodeAssign When Provider Documents…
H11.002”Pterygium, left eye” — no further type specified (NOS)
H11.012Amyloid pterygium, left eye — amyloid deposits confirmed histologically
H11.022Central pterygium, left eye — pterygium extends to or across the visual axis
H11.032Double pterygium, left eye — nasal AND temporal pterygium, same eye
H11.042Peripheral, stationary — documented as not progressing; stable on serial measurements
H11.052Peripheral, progressive — documented as actively growing; advancing toward visual axis
H11.062Recurrent pterygium, left eye — regrowth after prior surgical excision — do NOT use H11.002 for recurrent cases3
H11.812Pseudopterygium, left eye — secondary cicatricial adhesion; probe passes under limbus; Excludes1 to H11.0023

Before defaulting to H11.002, review the chart for any of these descriptors. A note documenting “growing pterygium” or “advancing pterygium” supports H11.052 (progressive); documentation of “history of prior pterygium excision” with regrowth supports H11.062 (recurrent).

Instructional Notes

Excludes1 — Mutually Exclusive

Cannot be coded together with H11.002 at the same encounter for the same eye:

  • Pseudopterygium of conjunctiva, left eye (H11.812) — a structurally and etiologically distinct entity representing secondary cicatricial adhesion following ocular surface trauma, chemical injury, or inflammation; mutually exclusive with true pterygium coding at the H11.0 level13

Also Excludes1 at the H11 Category Level

  • Keratoconjunctivitis (H16.2-) — classified separately and cannot be coded simultaneously as the same diagnosis expression for the same eye

No Excludes2 at H11.002 Level — Coexisting Conditions May Be Coded Separately

The following may be coded in addition to H11.002 when separately documented and confirmed:

  • Dry eye disease / keratoconjunctivitis sicca, left eye (H04.122) — pterygium commonly co-occurs with ocular surface dryness; both are separately reportable when present2
  • Corneal pannus or superficial corneal opacity, left eye — evaluate whether H18.892 (other specified corneal disorders, left eye) applies when significant corneal involvement is documented
  • Symptomatic pterygium-induced corneal astigmatism — corneal topography changes do not alter H11 code selection but should be documented for medical necessity

Use Additional Code

  • Z77.098 — Contact with and suspected exposure to other hazardous, chiefly nonmedicinal, chemicals — when provider explicitly links occupational outdoor UV exposure to pterygium development
  • H04.122 — Dry eye syndrome, left eye — code additionally when documented as a concurrent or contributing condition

Clinical Description

A pterygium is a benign but potentially vision-threatening fibrovascular proliferation of bulbar conjunctival tissue that crosses the corneal limbus and grows progressively onto the corneal surface.2 Histologically, the lesion consists of degenerated subepithelial connective tissue with fibrovascular proliferation, elastotic degeneration of collagen, and a surface layer of conjunctival epithelium — it is not a true neoplasm but an elastotic degenerative process driven primarily by chronic UV-B exposure and oxidative stress.2 The nasal limbus is the most common origin due to greater UV-B exposure from the corneal/limbal geometry and reflected light from the nasal side, though temporal pterygium does occur.

Pathophysiology:

  • Chronic UV-B radiation → oxidative damage to limbal stem cells → abnormal conjunctival epithelial proliferation and subconjunctival fibrovascular invasion of the corneal stroma2
  • Disruption of Bowman’s layer of the cornea at the advancing head of the pterygium
  • Associated with matrix metalloproteinase (MMP) upregulation driving fibrovascular invasion
  • Limbal stem cell dysfunction is a key contributing mechanism, explaining both the limbal origin and the high recurrence rate after surgical excision

Clinical Presentation:

  • Triangular or wing-shaped fleshy pink-red vascularized fibrovascular lesion arising most commonly from the nasal limbus of the left eye
  • Stocker’s line (iron line) may be visible at the advancing corneal head on slit lamp — a classic finding
  • Symptoms: redness, irritation, foreign body sensation, tearing, and induced corneal astigmatism — larger pterygia produce irregular astigmatism reducing corrected visual acuity14
  • Central pterygium (H11.022) involving the visual axis is an indication for surgery regardless of symptoms
  • Serial corneal topography is essential to monitor progression and quantify induced astigmatism

Pterygium Subtypes (All Unspecified When Not Documented → H11.002):

SubtypeClinical FeatureSurgical Urgency
Peripheral stationaryNot advancing; stable on serial topographyMonitor; surgery if symptomatic
Peripheral progressiveActively growing; advancing on serial topographySurgical excision recommended
CentralHas reached or crossed the visual axisSurgical — threatens visual function
DoubleNasal AND temporal pterygium, same left eyeIncreased surgical complexity
AmyloidAmyloid deposits confirmed histopathologicallySurgical; histology-driven subtype
RecurrentRegrowth after prior excisionMost aggressive; conjunctival autograft or amniotic membrane preferred14

Coding Guidelines

Official Guideline Reference

ICD-10-CM Official Guidelines FY2026, Section I.C.7 — Diseases of the Eye and Adnexa

  • Assign H11.002 when the provider documents pterygium of the left eye without specifying the clinical subtype. If the provider note, slit lamp findings, or surgical documentation describes the pterygium as progressive, stationary, central, double, amyloid, or recurrent, use the appropriate subtype-specific left-eye code from H11.012-H11.062.3
  • H11.002 and H11.812 (pseudopterygium, left eye) are mutually exclusive (Excludes1) — the clinical and probe test distinctions must be documented before code assignment.3
  • When pterygium is the primary reason for a pre-operative or surgical visit, H11.002 is the first-listed/principal diagnosis.
  • H11.062 (recurrent pterygium, left eye) should be assigned — not H11.002 — when prior excision is documented and the pterygium has regrown. Surgical history and PMH must be reviewed before defaulting to the unspecified code.

Sequencing Tips

  • Outpatient — First-listed diagnosis: H11.002 when pterygium is the primary reason for the encounter
  • Pre-operative visits and surgical encounter: H11.002 (or appropriate subtype) is the first-listed diagnosis
  • Incidental finding: Code as an additional diagnosis when documented and addressed alongside another primary ocular condition
  • POA (inpatient): Virtually always Y — pterygium is a chronic, slowly progressive condition. POA = N is essentially never applicable.
  • Recurrence: After surgical excision, if regrowth occurs, retire H11.002 and assign H11.062 — one of the most missed coding upgrade opportunities in anterior segment practices
  • Bilateral documentation: If the right eye is also affected, use H11.003 (bilateral, unspecified) rather than H11.001 + H11.002 per ICD-10-CM bilateral coding convention3

HCC Mapping

HCC Risk Adjustment

HCC Relevant: No HCC Model: CMS-HCC v28 — fully operative CY2026 HCC Category: Not mapped HCC Coefficient: 0.000 Risk Adjustment Impact: None

H11.002 carries no HCC weight under CMS-HCC v28.67 Pterygium is classified as a benign, non-systemic, anterior segment condition and does not meet the clinical severity threshold for HCC mapping under any version of the CMS-HCC model.

Associated HCC Opportunities

While H11.002 carries no HCC weight, verify and capture the following if documented in pterygium patients:

  • Type 2 diabetes with ophthalmic complications — diabetic retinopathy codes (E11.3x-) carry HCC 122 weight under V28; capture separately if documented7
  • Glaucoma — pterygium commonly coexists with glaucoma in UV-exposed populations; certain glaucoma codes carry HCC weight depending on severity and type under V28
  • AMD — capture with relevant HCC weight per V28 mapping if coexisting and documented

MS-DRG Mapping

DRG Assignment

MS-DRGDescriptionMDCGMLOS
124Other Disorders of the Eye with MCCMDC 24.6
125Other Disorders of the Eye with CCMDC 23.1
126Other Disorders of the Eye without CC/MCCMDC 22.2

CC/MCC Status & Inpatient Context

  • CC status: No
  • MCC status: No
  • HAC designation: No
  • POA exempt: No
  • Inpatient note: Inpatient admission for left-eye pterygium excision alone is extremely rare — pterygium surgery (65420 or 65426) is almost universally performed in an outpatient ASC or office-based setting. H11.002 most commonly appears as a secondary diagnosis in the inpatient setting when combined with another ocular procedure. As the sole diagnosis, H11.002 would group to MS-DRG 126 in the absence of CC/MCC diagnoses.4 When a qualifying ICD-10-PCS surgical procedure is performed (excision of left conjunctiva — 08B33ZZ), the case may group to a surgical MS-DRG within MDC 02.

CPT Crosswalk

CPTDescriptionwRVU (approx.)Global PeriodAsst. Payable (Medicare)
92004Ophthalmological exam, new patient, comprehensive, with dilation2.670 daysN/A — E/M
92014Ophthalmological exam, established patient, comprehensive, with dilation1.340 daysN/A — E/M
92025Computerized corneal topography, unilateral or bilateral, with interpretation and report0.00 (TC/PC split)0 daysN/A — Diagnostic
92250Fundus photography with interpretation and report0.00 (TC/PC split)0 daysN/A — Diagnostic
65430Scraping of cornea, diagnostic, for smear and/or culture0.850 daysN/A — Diagnostic
65420Excision or transposition of pterygium; without graft~3.0090 days⚠️ Verify MPFS indicator
65426Excision or transposition of pterygium; with graft~5.4790 days⚠️ Verify MPFS indicator
68100Biopsy of conjunctiva~1.000 daysN/A — Diagnostic

65420 vs. 65426 — Key Surgical CPT Decision

CodeProcedureWhen to AssignRecurrence Risk
65420Excision or transposition — without graftBare sclera technique; no conjunctival or amniotic membrane graft placedHigh recurrence (~30-80%)
65426Excision or transposition — with graftConjunctival autograft (CAU) or amniotic membrane transplant (AMT) placed following excisionLower recurrence (~5-15%) — current standard of care14
  • Operative note must document graft placement to support 65426
  • Mitomycin C (MMC) alone does NOT constitute a graft — MMC post-excision does not upgrade 65420 to 65426
  • Conjunctival autograft: document harvest site, graft dimensions, and fixation method (suture vs. fibrin glue)
  • Amniotic membrane graft: document product name and lot number (e.g., Prokera, AmnioGraft)14
  • Always append modifier -LT to 65420 or 65426 for left-eye procedures

NCCI Bundling — Pterygium CPT Codes

  • 65420 and 65426 are mutually exclusive per NCCI edits — never bill both for the same eye on the same date11
  • Review current NCCI edit pairs before billing any additional conjunctival graft CPT alongside 65426

Modifier -LT Required on Surgical Claims

Append modifier -LT (left side) to 65420 or 65426 for all left eye pterygium excision claims. Failure to append -LT may result in claim rejection or bilateral billing flags, particularly when the same CPT was recently billed for the right eye on the same patient.3

ICD-10-PCS Crosswalk

PCS Applicability

ICD-10-PCS applies in the inpatient setting only. The body part coded for pterygium excision is the conjunctiva (body part 3 = conjunctiva, left), not the cornea — the pterygium originates from conjunctival tissue even though it involves the corneal surface.

PCS CodeRoot OperationBody PartApproachDeviceQualifier
08B33ZZExcisionConjunctiva, LeftPercutaneousNo DeviceNo Qualifier
08T33ZZResectionConjunctiva, LeftPercutaneousNo DeviceNo Qualifier
08R3X73ReplacementConjunctiva, LeftExternalAutologous Tissue SubstituteNo Qualifier

Character breakdown — excision of left conjunctiva (08B33ZZ):

  • Section: 0 — Medical and Surgical
  • Body System: 8 — Eye
  • Root Operation: B — Excision
  • Body Part: 33 — Conjunctiva, Left
  • Approach: 3 — Percutaneous
  • Device: Z — No Device
  • Qualifier: Z — No Qualifier

PCS Root Operation Distinction

  • Excision (08B33ZZ) — portion of conjunctiva removed (typical for pterygium excision)
  • Resection (08T33ZZ) — entire left conjunctiva removed; not typical for pterygium alone
  • Replacement (08R3X73) — applicable when conjunctival autograft is placed; device character 7 = Autologous Tissue Substitute

ICD-10-CM Crosswalk

CodeDescriptionRelationship
H11.001Unspecified pterygium, right eyeContralateral equivalent
H11.003Unspecified pterygium, bilateralBilateral equivalent — use when both eyes affected
H11.009Unspecified pterygium, unspecified eyeLess specific — avoid if laterality documented
H11.012Amyloid pterygium, left eyeUse when amyloid deposits confirmed histologically
H11.022Central pterygium, left eyeUse when visual axis is threatened or involved
H11.032Double pterygium, left eyeUse when nasal AND temporal pterygium present
H11.042Peripheral pterygium, stationary, left eyeUse when documented as stable/non-progressing
H11.052Peripheral pterygium, progressive, left eyeUse when documented as actively advancing
H11.062Recurrent pterygium, left eyeUse after prior excision with regrowth — do not use H11.002 for recurrence
H11.812Pseudopterygium of conjunctiva, left eyeExcludes1 — secondary cicatricial adhesion; not a true pterygium
H18.892Other specified disorders of cornea, left eyeAssociated corneal pannus or scarring from advanced pterygium
H04.122Dry eye syndrome, left eyeMay coexist — separately reportable
H16.212Exposure keratoconjunctivitis, left eyeMay coexist in advanced cases
Z77.098Contact with/exposure to other hazardous nonmedicinal chemicalsUV exposure history relevant to pterygium etiology

Coding Examples

Example 1 — Outpatient New Patient Visit, Left Eye Pterygium, No Surgery

Scenario: A 49-year-old outdoor landscaper presents as a new patient complaining of a visible growth and irritation on the left eye. Slit lamp exam reveals a pink fleshy fibrovascular growth arising from the nasal limbus of the left eye, not yet approaching the visual axis. Provider documents “pterygium, left eye” — no further subtype specified. Artificial tears recommended; surgery deferred.

First-listed Dx: H11.002 — Unspecified pterygium of left eye CPT: 92004--LT — Comprehensive ophthalmological exam, new patient, with dilation Notes: No subtype documented — H11.002 is correct. If the provider noted “advancing” or documented growth on topography, H11.052 would be more specific.

Example 2 — Established Patient, Pre-operative Evaluation, Left Eye, Progressive

Scenario: A 55-year-old established patient with serial topography confirming progressive growth toward the visual axis of the left eye. Provider documents “progressive peripheral pterygium, left eye — surgical excision with conjunctival autograft recommended.”

First-listed Dx: H11.052 — Peripheral pterygium, progressive, left eye (more specific than H11.002 — type is documented) CPT: 92014--LT; 92025--LT — Corneal topography Notes: H11.002 would be incorrect here — the progressive type is documented. This is a prime example of retiring the unspecified code in favor of its specific sibling.

Example 3 — Surgical Case, Pterygium Excision with Conjunctival Autograft, Left Eye

Scenario: A 43-year-old patient undergoes pterygium excision of the left eye. Operative note documents: “Excision of pterygium, left eye. Conjunctival autograft harvested from superior bulbar conjunctiva and secured with fibrin glue (Tisseel). Dimensions: 7 x 5 mm. Pterygium NOS.”

CPT: 65426--LT — Excision or transposition of pterygium, with graft, left eye ICD-10-CM: H11.002 — Unspecified pterygium of left eye Notes: 65426 is correct — conjunctival autograft with fibrin glue fixation is explicitly documented. Billing 65420 here would be undercoding. Graft harvest site, dimensions, and fixation method are all present in the note — the three key elements needed to survive audit.1011

Example 4 — Recurrent Pterygium, Left Eye — Post-Excision Regrowth

Scenario: An established patient who had left eye pterygium excision 18 months ago returns with documented regrowth of fibrovascular tissue at the nasal limbus. Provider documents “recurrent pterygium, left eye — previously excised.”

First-listed Dx: H11.062 — Recurrent pterygium of left eye (do NOT use H11.002) CPT (if re-excision performed): 65426--LT Notes: H11.002 is incorrect for recurrent cases — H11.062 is required once prior excision and regrowth are documented. Conjunctival autograft or amniotic membrane is strongly preferred for recurrent cases; 65426 is almost universally appropriate.14

Example 5 — Bilateral Pterygium, Both Eyes Unspecified

Scenario: A 57-year-old patient with pterygium affecting both eyes. Provider documents “bilateral pterygium — left eye more advanced; type unspecified for either eye.”

First-listed Dx: H11.003 — Unspecified pterygium, bilateral (use bilateral code — do NOT code H11.001 + H11.002 separately) CPT (if treating left eye only today): 65426--LT Notes: H11.003 is required per bilateral coding convention. The bilateral ICD-10-CM code remains appropriate even when only one eye is being treated surgically at this encounter — append -LT to the CPT to indicate the left eye is the treated side.3

Example 6 — Left Eye Pterygium, Inpatient Secondary Dx, Combined Procedure

Scenario: A 66-year-old patient admitted for complex cataract extraction with IOL placement, left eye. Incidental left eye pterygium is noted and documented in the ophthalmology note — no treatment rendered for pterygium during this admission.

Principal Dx: H26.012 — Combined forms of subcapsular cataract, left eye (reason for admission) Additional Dx: H11.002 — Unspecified pterygium of left eye (documented, examined, no treatment this admission) POA: Y — pterygium is a chronic condition present prior to admission

Coding Pitfalls & Tips

Common Errors

  • Using H11.002 for recurrent pterygium — once prior excision is documented and regrowth has occurred, H11.062 is required; this is the most persistently missed upgrade in anterior segment coding
  • Confusing H11.002 and H11.812 (pseudopterygium, left eye) — these are Excludes1 to each other; both cannot be assigned for the same encounter on the same eye3
  • Billing 65420 when a graft was placed — if the operative note documents autograft or amniotic membrane, 65426 must be billed regardless of whether the code selected was originally 65420
  • Forgetting modifier -LT on surgical claims — laterality modifiers are required for all unilateral left-eye surgical CPT codes; omission causes claim denials and bilateral billing alerts
  • Coding H11.009 (unspecified eye) when the left eye is clearly documented — always assign H11.002
  • Coding H11.001 + H11.002 simultaneously for bilateral pterygium — use H11.003 per bilateral coding convention3
  • MMC as a graft — Mitomycin C application does not constitute a graft; do not upgrade 65420 to 65426 based solely on MMC use

Pro Tips

  • Review the full slit lamp documentation and serial topography before assigning H11.002 — clinical descriptors like “encroaching on the visual axis,” “advancing,” “stable,” or “history of prior excision with regrowth” all support more specific sibling codes
  • Document the subtype explicitly — even the distinction between stationary and progressive changes surgical timing and drives a more specific ICD-10 code with better clinical granularity
  • Serial topography distinguishing H11.042 (stationary) from H11.052 (progressive) is strong medical necessity documentation — reference topography data in the provider assessment, not just the imaging report
  • 90-day global period for 65420 and 65426 means all related follow-up during the global window is bundled; modifier -24 applies for unrelated E/M services during the global period
  • In bilateral pterygium patients, document each eye individually at every encounter and note which eye is primary for surgical planning — this supports correct laterality modifier assignment on CPT claims even when the bilateral ICD-10 code (H11.003) is used

CDI Query Opportunities

CDI Flags

  • Subtype documentation: What is the clinical type — stationary peripheral, progressive peripheral, central, double, or amyloid? Query the provider to retire H11.002 in favor of a more specific sibling code
  • Recurrence history: Has this patient had prior pterygium excision on the left eye? If so and regrowth is present, H11.062 is required — query if surgical history is present but “recurrent” is not explicitly stated in the note
  • True pterygium vs. pseudopterygium: Has a probe test been performed? Query if documentation is ambiguous about true limbal attachment
  • Bilateral involvement: Is the right eye also affected? Query for right eye examination findings → update to H11.003 if bilateral involvement is confirmed
  • Graft type for surgical cases: Conjunctival autograft? Amniotic membrane? Document explicitly — drives 65420 vs. 65426 and must be auditable in the operative note
  • Associated dry eye: Is concurrent dry eye disease (H04.122) documented and being treated? Both conditions should be coded when present
  1. AAPC Codify — ICD-10-CM H11.002 & H11.0 Excludes1 Notes, aapc.com
  2. Unbound Medicine — H11.001/H11.002 Pterygium of Eye, unboundmedicine.com
  3. CMS — ICD-10-CM Official Guidelines for Coding and Reporting FY2026, cms.gov
  4. CMS — ICD-10-CM/PCS MS-DRG v37.2 Definitions Manual, cms.gov
  5. FindACode — ICD-10-CM H11.002, findacode.com
  6. MedPAC — MA Part D CY2027 Comment Letter, medpac.gov (2026)
  7. BCA — HCC Updates: Capturing Risk Accurately in 2026, bcarev.com (2026)
  8. Wolters Kluwer — How CMS-HCC Version 28 Will Impact RAF Scores, wolterskluwer.com
  9. AAPC — CPT Code 65426 Excision Procedures on the Cornea, aapc.com
  10. AAPC — CPT Code 65420 Excision Procedures on the Cornea, aapc.com
  11. CMS — 2026 NCCI Medicare Coding Policy Manual, cms.gov
  12. Review of Ophthalmology — Coding and Reimbursement: 2026 Update, reviewofophthalmology.com (2026)
  13. GenHealth.ai — ICD-10-CM H11.0 Pterygium of Eye, genhealth.ai
  14. MD Clarity — CPT Code 65426: What It Is, Modifiers, Reimbursement, mdclarity.com
  15. AAPC — ICD-10-CM H11.81 Pseudopterygium of Conjunctiva, aapc.com
  16. CMS — ICD-10-CM/PCS MS-DRG v33.0 Definitions Manual, cms.gov

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