H57.051

🧬 ICD-10 CM H57.051 — Tonic Pupil, Right Eye

Billable Code Confirmed

ICD-10-CM H57.051 is a valid, billable 6-character ICD-10-CM code for FY2026. Characters 1-3 (H57) define the category “Other disorders of eye and adnexa”; character 4 (0) narrows to anomalies of pupillary function; character 5 (5) specifies tonic pupil; and character 6 (t) specifies right eye laterality. No additional characters are required.

Non-Billable Parent Codes — Never Submit These

• ❌ H57 — 3-character header — does not specify type of ocular disorder
• ❌ H57.0 — 4-character header — does not specify which pupillary anomaly
• ❌ H57.05 — 5-character header — does not specify laterality

Always submit H57.051 (all 6 characters) when tonic pupil of the right eye is documented.

Clinical Context: Light-Near Dissociation and Cholinergic Supersensitivity

ICD-10-CM H57.051 captures tonic pupil of the right eye, a condition caused by acute denervation of the ciliary ganglion resulting in a large, poorly light-reactive pupil that constricts tonically to near stimulation (light-near dissociation) and demonstrates supersensitivity to dilute pilocarpine (0.1%). This pharmacologic response is pathognomonic and distinguishes tonic pupil from other causes of mydriasis.

Code Classification

ICD-10-CM Diagnosis Code — wRVU, assistant-at-surgery payable, and global period fields are not applicable to this diagnosis code. For procedural coding associated with this diagnosis, refer to the CPT Procedural Crosswalk and ICD-10-PCS Crosswalk sections below.

---

🔍 Code Description

ICD-10 CM H57.051 classifies tonic pupil of the right eye, a condition resulting from injury to the parasympathetic supply of the iris sphincter and ciliary body via the ciliary ganglion in the retrobulbar space. The affected pupil is characteristically dilated (mydriatic), poorly or non-reactive to direct light, and constricts slowly and tonically with near fixation — a finding termed light-near dissociation.^2^

The ciliary ganglion injury leads to cholinergic supersensitivity within days of onset, making the denervated iris sphincter hypersensitive to low concentrations of muscarinic agonists. When tonic pupil occurs with ipsilateral or generalized tendon areflexia, the complete syndrome is termed Adie syndrome (or Holmes-Adie syndrome). In many patients, especially young women, no underlying etiology is identified (idiopathic Adie syndrome); secondary causes include viral infection, orbital trauma, autoimmune neuropathy, and diabetic autonomic neuropathy.^3^^4^^5^

---

🌳 Code Tree / Hierarchy

H57 — Other disorders of eye and adnexa ❌ Non-billable
│
├── H57.0 — Anomalies of pupillary function ❌ Non-billable header
│   │
│   ├── H57.00 — Unspecified anomaly of pupillary function ✅ Billable
│   ├── H57.01 — Argyll Robertson pupil, atypical ✅ Billable
│   ├── H57.02 — Anisocoria ✅ Billable
│   ├── H57.03 — Miosis ✅ Billable
│   ├── H57.04 — Mydriasis ✅ Billable
│   ├── H57.05 — Tonic pupil ❌ Non-billable header
│   │   ├── H57.051 — Tonic pupil, right eye ✅ Billable
│   │   ├── H57.052 — Tonic pupil, left eye ✅ Billable
│   │   ├── H57.053 — Tonic pupil, bilateral ✅ Billable
│   │   └── H57.059 — Tonic pupil, unspecified eye ✅ Billable
│   │       ← H57.051 IS HERE ◀
│   └── H57.09 — Other anomalies of pupillary function ✅ Billable
│
├── H57.1 — Ocular pain ❌ Non-billable header
└── H57.8 — Other specified disorders of eye and adnexa ❌ Non-billable header

Never Submit H57.05

H57.05 is a 5-character non-billable header. Laterality must be documented before a billable code can be assigned. If the provider documents “tonic pupil” without specifying which eye, send a CDI query — clinical examination findings (direct vs. consensual light response asymmetry, slit-lamp segmental iris contractions) will identify the affected side. Only use H57.059 when laterality is genuinely unestablished after query.

---

✅ Includes

The following clinical terms and scenarios map to H57.051 when documented:

• Tonic pupil, right eye
• Adie pupil, right eye
• Adie syndrome (pupillary component), right eye
• Holmes-Adie pupil, right eye
• Adie-Holmes syndrome, right eye
• Light-near dissociation, right eye
• Cholinergic supersensitivity of iris sphincter, right eye
• Ciliary ganglion denervation (pupillary manifestation), right eye

---

❌ Excludes

Excludes 1 — Cannot Be Coded Simultaneously with H57.051

Code	Description	Note
No official Excludes 1 restrictions	—	H57.051 has no Excludes 1 restrictions in FY2026

Excludes 1 Violation Risk

Do not report H57.051 alongside H57.04 (Mydriasis) for the same eye on the same encounter — while tonic pupil presents with mydriasis, the specific tonic pupil code fully captures this finding. Coding both for the same eye is redundant and constitutes a specificity error. H57.04 may be used for the unaffected fellow eye only if separately documented.

Excludes 2 — May Be Coded in Addition if Separately Present

Code	Description	Note
No official Excludes 2 restrictions	—	Underlying etiologic diagnoses (neuropathy, autoimmune, infectious) should be coded additionally per ICD-10-CM convention

---

📋 Clinical Overview

Tonic Pupil vs. Other Causes of Mydriasis

Accurate differential coding requires distinguishing tonic pupil from other mydriatic conditions, as each maps to a different ICD-10-CM code with distinct clinical and coding implications.

Feature	H57.051 — Tonic Pupil Right Eye	H57.04 — Mydriasis	H57.02 — Anisocoria
Pupil Size	Large (mydriatic), right eye	Large (any eye)	Asymmetric bilaterally
Light Reaction	Absent or very slow	Variable	Normal or abnormal
Near Reaction	Slow, tonic constriction (light-near dissociation)	Variable	Not the defining feature
Pilocarpine 0.1% Response	Constricts (supersensitivity)	No response	Not diagnostic
Slit-Lamp Finding	Segmental iris sphincter contractions	None specific	None specific
Associated Findings	Tendon areflexia (Adie syndrome)	Pharmacologic, CN III palsy	Ptosis, anhidrosis
Code	H57.051	H57.04	H57.02

CDI Query Trigger — "Dilated Pupil" Without Specificity

When a provider documents “dilated pupil” or “mydriasis” of the right eye with light-near dissociation on exam or a positive pilocarpine test noted in the chart, query the provider to confirm whether this represents a tonic pupil (Adie pupil). Confirmation allows assignment of the more specific H57.051 over the generic H57.04 (Mydriasis), more accurately capturing the underlying autonomic mechanism.

Manifestations & Symptom Burden

Common presenting signs and associated manifestations that should be coded when separately documented:

• H57.02 — Anisocoria: Unequal pupil size is a presenting finding in the majority of tonic pupil cases; code separately if the provider documents it as a distinct finding
• Tendon areflexia / M62.81 — Muscle weakness: Deep tendon reflex loss or diminishment is the hallmark of complete Adie syndrome
• H52.0x — Hyperopia (accommodative paresis): Ciliary body denervation causes loss of accommodation, resulting in functional hyperopia in affected younger patients
• G90.09 — Other idiopathic peripheral autonomic neuropathy: When the provider documents autonomic involvement beyond the eye (e.g., anhidrosis, orthostatic hypotension) as part of Adie syndrome

Coding Manifestations

Always code documented manifestations to fully capture patient complexity. Examples:

• H57.02 — Anisocoria (if separately documented)
• H52.01 or H52.02 — Hyperopia with accommodative paresis, right or left eye
• G90.09 — Idiopathic peripheral autonomic neuropathy (if Adie syndrome with systemic features is confirmed)

---

💰 HCC Risk Adjustment (CMS-HCC v28)

Field	Detail
CMS-HCC Model Version	v28 (2024-2025 Implementation)
HCC Assignment	❌ Not HCC-Mapped
HCC Category	N/A
RAF Coefficient	N/A

H57.051 does not map to an HCC under CMS-HCC v28 and does not independently contribute to RAF score.^6^

Capture Underlying Etiology for RAF

While H57.051 is not HCC-mapped, secondary etiologic diagnoses documented alongside tonic pupil frequently are. Diabetic autonomic neuropathy (E11.40-E11.49), Charcot-Marie-Tooth disease (G60.0), and syphilitic neuropathy (A52.15) all carry potential HCC mapping. Always code the etiology when documented to ensure defensible RAF scores under CMS-HCC v28 audit standards.^6^

---

🏥 MS-DRG Assignment

MDC 02 — Diseases and Disorders of the Eye

DRG	Title	Est. Relative Weight*
DRG 124	Other Disorders of the Eye with MCC	~0.95-1.10
DRG 125	Other Disorders of the Eye with CC	~0.70-0.85
DRG 126	Other Disorders of the Eye without CC/MCC	~0.50-0.65

Approximate. Verify against IPPS FY2026 Final Rule tables.

Sequencing and Complications

H57.051 sequences under MDC 02 when it is the principal inpatient diagnosis — which is uncommon, as tonic pupil is rarely the primary reason for acute admission. When it is a secondary diagnosis reflecting an underlying systemic neurological or infectious condition that drove the admission, sequence that condition as principal. H57.051 does not function as a CC or MCC when secondary, and does not independently shift DRG weight.^7^

---

🔗 Related ICD-10-CM Codes

Tonic Pupil Laterality Variants

Code	Description
H57.051	Tonic pupil, right eye
H57.052	Tonic pupil, left eye
H57.053	Tonic pupil, bilateral
H57.059	Tonic pupil, unspecified eye

Pupillary Anomaly Family (H57.0x)

Code	Description
H57.00	Unspecified anomaly of pupillary function
H57.01	Argyll Robertson pupil, atypical
H57.02	Anisocoria
H57.03	Miosis
H57.04	Mydriasis
H57.09	Other anomalies of pupillary function

Common Etiologic Codes (Code Also When Documented)

Code	Description
G90.09	Other idiopathic peripheral autonomic neuropathy (Adie syndrome, autonomic features)
E11.40	Type 2 diabetes mellitus with diabetic neuropathy, unspecified
G60.0	Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth)
A52.15	Late syphilitic neuropathy
B02.34	Zoster ocular disease (herpes zoster ciliary ganglionitis)

---

🛠️ Commonly Associated CPT Codes (Ophthalmology / Neuro-Ophthalmology)

Outpatient and Profee Setting Context

These CPT codes are most commonly associated with the evaluation of tonic pupil in the outpatient ophthalmology or neuro-ophthalmology setting. When pharmacologic pupil testing is performed as part of the examination, it is typically included in the E/M service value and not separately billed under most payer policies. Append Modifier -25 to the E/M code if a separately identifiable procedure is performed on the same date.

CPT Code	Description	Profee Coding Notes
92004	Ophthalmological services, new patient, comprehensive	Bill for new patient presenting with tonic pupil; includes slit-lamp, pupillary, and dilute pilocarpine test documentation
92014	Ophthalmological services, established patient, comprehensive	Established patient follow-up for known tonic pupil or Adie syndrome
99213-99215	Office/outpatient E/M, established patient	Neurology or neuro-ophthalmology E/M; Modifier -25 if separate procedure performed
92081-92083	Visual field examination	May be ordered to assess for associated visual field defects or optic pathway involvement
95923	Testing of autonomic nervous system function	Autonomic testing when Adie syndrome with systemic autonomic features is suspected

NCCI Bundling Considerations

• Autonomic function testing (95923) billed on the same day as E/M services (99213-99215) requires Modifier -25 on the E/M to confirm a separately identifiable service was performed and documented beyond the testing indication alone.

---

🔬 ICD-10-PCS Crosswalk (Inpatient Procedures)

When H57.051 appears as an inpatient diagnosis, these PCS codes may apply to workup procedures targeting the underlying etiology.

PCS Section	Body System	Root Operation	Clinical Application
3 (Administration)	8 (Eye)	0 (Introduction)	Pharmacologic instillation of dilute pilocarpine (0.1%) to confirm cholinergic supersensitivity — example PCS: 3E0C3GC
0 (Medical and Surgical)	R (Upper Joints)	J (Inspection)	Lumbar puncture for CSF analysis when infectious etiology (e.g., syphilis, viral ganglionitis) is suspected — example PCS: 009U3ZX

---

💊 Coding Scenarios and Examples

---

Scenario 1 — Outpatient Ophthalmology: New-Onset Tonic Pupil, Idiopathic

Clinical Vignette: A 28-year-old female presents to ophthalmology reporting that her right pupil has looked “bigger than the other one” for about three weeks. She denies diplopia, ptosis, or headache. Slit-lamp examination reveals segmental contractions of the right eye iris sphincter. Dilute pilocarpine 0.1% instilled into the right eye eye produces brisk constriction, confirming cholinergic supersensitivity. No systemic etiology is identified. The provider documents: “Adie tonic pupil, right eye, idiopathic.”

CPT (Profee):

• 92004 — Ophthalmological services, new patient, comprehensive

ICD-10-CM:

• H57.051 — Tonic pupil, right eye (principal/first-listed; idiopathic, no additional etiologic code)
• H57.02 — Anisocoria (if separately documented as a distinct finding)

---

Scenario 2 — Neurology Outpatient: Adie Syndrome with Areflexia

Clinical Vignette: A 35-year-old female with a known history of Adie syndrome is seen by neurology for annual follow-up. Examination confirms persistent tonic pupil of the right eye with light-near dissociation and absent knee and ankle deep tendon reflexes bilaterally. She reports difficulty reading at near distances due to accommodative paresis. The provider documents: “Adie syndrome — tonic pupil right eye, tendon areflexia, accommodative paresis.”

Principal Diagnosis:

• H57.051 — Tonic pupil, right eye (primary ophthalmologic finding driving the visit)

Secondary Diagnoses:

• G90.09 — Other idiopathic peripheral autonomic neuropathy (Adie syndrome with systemic autonomic features)
• H52.01 — Hyperopia (accommodative paresis functional equivalent, if documented)

MS-DRG Assignment: Outpatient setting — DRG does not apply. In an inpatient scenario, G90.09 as principal would shift to MDC 01.

---

Scenario 3 — CDI Query: “Dilated Pupil” Without Tonic Features Documented

Clinical Vignette: An inpatient neurology note reads: “Right pupil 6 mm, sluggishly reactive to light. No ptosis or ophthalmoplegia noted. CN III intact.” The coder reviews the record and notes the patient is a 32-year-old female admitted for unrelated syncope. A prior ophthalmology note from six months ago references “Adie pupil right eye.” The current note does not use the term “tonic pupil.”

Action / Outcome: “Sluggishly reactive” and the prior ophthalmology reference create enough clinical context to query, but the coder cannot code from a prior encounter note. A CDI query should be sent to the inpatient neurologist asking whether the right pupil finding represents the patient’s known Adie tonic pupil.

Query Response: Provider updates current note to confirm: “Right mydriatic pupil with sluggish light response consistent with patient’s known Adie tonic pupil, right eye — chronic, stable.”

Corrected ICD-10-CM Coding:

• H57.051 — Tonic pupil, right eye (now supported by current encounter documentation)

---

⚠️ Coding Pitfalls and Tips

	Pitfall or Tip
❌	Submitting H57.05 (the non-billable parent). H57.05 is a 5-character header code and will be rejected or denied. Always code to the 6-character laterality-specific level: H57.051-H57.059.
❌	Coding H57.04 (Mydriasis) instead of H57.051. Tonic pupil presents with mydriasis, but when the specific diagnosis of tonic pupil or Adie pupil is documented, H57.051 is the correct and more specific code — do not downcode to the generic mydriasis code.
❌	Failing to code the underlying etiology. When a cause is documented (diabetic neuropathy, herpes zoster, syphilis, autoimmune neuropathy), code it additionally. Tonic pupil is a manifestation; the etiology should also be captured.
✅	Use dilute pilocarpine test findings as a CDI trigger. A positive pilocarpine 0.1% response documented in the chart is pathognomonic for tonic pupil and supports querying for a definitive diagnosis when the provider uses vague language like “dilated pupil” or “mydriasis.”
✅	Code accommodative paresis separately when documented. Young patients with tonic pupil often have ciliary body dysfunction causing accommodative paresis — document-supported accommodative failure maps to H52.0x and captures additional clinical complexity.
✅	Query laterality before defaulting to H57.059. H57.059 (unspecified eye) should be used only after a CDI query has been sent and laterality genuinely cannot be established from documentation or clinical context. Slit-lamp findings, pilocarpine test records, and prior ophthalmology notes often establish the affected side.

---

📚 Sources

1. CMS/NCHS. ICD-10-CM Official Guidelines for Coding and Reporting, FY2026.
2. Thompson HS, Kardon RH. (2006). The Adie tonic pupil. Journal of Neuro-Ophthalmology, 26(1), 40-46. (Source for ciliary ganglion denervation mechanism, pilocarpine supersensitivity, and Adie syndrome pathophysiology.)
3. Suhler E, et al. (2022). Adie’s Pupil: A Diagnostic Challenge for the Physician. PMC/NIH, PMC8917782. (Source for clinical presentation, demographics, and pharmacologic testing.)
4. Prasad S, Bhatt DL. (2022). Adie’s tonic pupil. Case-Based Neuro-Ophthalmology, Pressbooks. (Source for ciliary ganglion injury, segmental iris contraction, and slit-lamp findings.)
5. Cleveland Clinic. (2025). Adie Syndrome (Tonic Pupil): Causes, Symptoms & Treatment. (Source for clinical signs, deep tendon reflexes, and management overview.)
6. CMS. 2025-2026 Medicare Advantage Risk Adjustment — CMS-HCC Model v28 ICD-10-CM Mappings.
7. CMS. IPPS Final Rule FY2026 — MS-DRG Definitions Manual v43. MDC 02 — Diseases and Disorders of the Eye logic tables.
8. AMA. CPT Professional Edition 2026. Surgery / Eye and Ocular Adnexa; Evaluation and Management subsections.