🧬 ICD-10 CM H02.001 — Unspecified Entropion of Right Upper Eyelid
Billable Code Confirmed
ICD-10-CM H02.001 is a valid, billable 6-character diagnosis code. The first three characters (H02) specify other disorders of the eyelid, the 4th and 5th characters (00) specify unspecified entropion, and the 6th character (1) specifically denotes the right upper eyelid. No additional characters are required.
Non-Billable Parent Codes — Never Submit These
Clinical Context: Specificity vs. Unspecified
H02.001 indicates the provider did not specify the etiology of the entropion (e.g., senile, cicatricial, mechanical, or spastic). While this is a billable code, best coding practice dictates querying the provider or examining the documentation for a specific underlying cause, as using unspecified codes may lead to denials or requests for additional records from certain payers.
Code Classification
ICD-10-CM Diagnosis Code — wRVU, assistant payable, and global period fields are not applicable. See CPT Procedural Crosswalk and ICD-10-PCS Crosswalk sections for associated procedural billing.
🔍 Code Description
ICD-10-CM H02.001 classifies Unspecified entropion of right upper eyelid.
Pathophysiology: Entropion is a condition in which the eyelid margin turns inward against the globe. This inward turning causes the eyelashes (trichiasis) and skin to rub against the corneal and conjunctival surfaces, leading to severe irritation, foreign body sensation, reflex tearing (epiphora), and potential corneal abrasion or ulceration if left untreated.
Because this code is “unspecified,” it does not state whether the entropion is age-related (senile), due to scarring (cicatricial), muscle spasms (spastic), or secondary to a mass (mechanical). It specifically identifies the anatomical location as the upper lid of the right eye.
🌳 Code Tree / Hierarchy
H02 Other disorders of eyelid ❌ Non-billable
│
├── H02.0 Entropion and trichiasis of eyelid ❌ Non-billable
│ ├── H02.00 Unspecified entropion of eyelid ❌ Non-billable
│ │ ├── H02.001 Unspecified entropion of right upper eyelid ◀ THIS CODE ✅ Billable
│ │ ├── H02.002 Unspecified entropion of right lower eyelid ✅ Billable
│ │ └── H02.003 Unspecified entropion of right eye, unspecified eyelid ✅ Billable
│ │
│ ├── H02.01- Cicatricial entropion of eyelid
│ ├── H02.02- Mechanical entropion of eyelid
│ ├── H02.03- Senile entropion of eyelid
│ └── H02.04- Spastic entropion of eyelid
Seeking Greater Specificity
If the chart notes state “senile entropion,” do not use this code. Instead, use
H02.031(Senile entropion of right upper eyelid).
✅ Includes
The following clinical terms and scenarios map directly to H02.001 when documented:
- Entropion of right upper eyelid NOS
- Inward turning of the right upper eyelid
- Trichiasis caused by right upper eyelid entropion
❌ Excludes
Excludes 1 — Cannot Be Coded Simultaneously with CODE
| Code | Description | Note |
|---|---|---|
| Q10.0-Q10.3 | Congenital malformations of eyelid | Mutually exclusive. If the entropion is congenital (present at birth), use the appropriate congenital Q10.- code rather than an acquired eyelid disorder code.^1 |
📋 Clinical Overview
Common Triggers and Associated Symptoms
Patients with this condition typically present to an eye care specialist with:
- Foreign Body Sensation: Feeling like something is in the right eye.
- Epiphora: Excessive tearing.
- Conjunctival Injection: Redness of the right eye.
- Corneal Complications: Punctate epithelial erosions (PEE) or corneal abrasions caused by eyelash friction.
Documentation Requirements
To fully support the use of this code (and any eventual surgical repair), the provider should document:
- The exact eyelid involved (Right Upper).
- The severity of the symptoms (e.g., pain, tearing).
- The presence of secondary complications (e.g., corneal abrasions).
- Previous conservative treatments attempted (e.g., ocular lubricants, taping) before recommending surgical intervention.
💰 HCC Risk Adjustment (CMS-HCC v28)
| Field | Detail |
|---|---|
| CMS-HCC Model Version | v28 (2024-2025 Implementation) |
| HCC Assignment | ❌ Not Mapped |
| HCC Category | N/A |
H02.001 does not carry a risk adjustment weight under the CMS-HCC model, as it is a localized structural abnormality rather than a systemic chronic disease.
🏥 DRG Assignment
MDC 02 — Diseases and Disorders of the Eye
| DRG | Title |
|---|---|
| DRG 124 | Other Disorders of the Eye with MCC or Thrombolytic Agent |
| DRG 125 | Other Disorders of the Eye without MCC |
Note: Inpatient admission for entropion alone is virtually nonexistent. Surgical correction is almost exclusively an outpatient/ambulatory procedure.
🛠️ Commonly Associated CPT Codes (Ophthalmology / Outpatient)
Outpatient Surgical Context
The treatment for symptomatic entropion that fails conservative management is surgical repair.
| CPT Code | Description | Modifier Notes / wRVU |
|---|---|---|
| 92012 | Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient | Typical exam code for evaluation. (wRVU: 1.48 · Global: XXX) |
| 67921 | Repair of entropion; suture | Used for less complex, suture-based inversion repairs (e.g., Quickert sutures). Append modifier -E3. (wRVU: ~4.00 · Global: 090) |
| 67924 | Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation) | Used for formal, complex anatomical repairs. Append modifier -E3. (wRVU: ~7.00 · Global: 090) |
| 67820 | Correction of trichiasis; epilation, by forceps only | Temporary measure to remove rubbing lashes. Append modifier -E3. |
Note: The HCPCS E3 modifier indicates “Upper right, eyelid.”
💊 Coding Scenarios and Examples
Scenario 1 — Outpatient Oculoplastics Evaluation
Clinical Vignette: A 72-year-old female presents to the oculoplastics clinic complaining of constant irritation, tearing, and redness in her right eye for the past month. On slit-lamp examination, the physician notes that the right upper eyelid margin is inverted, causing the lashes to rub against the superior cornea. There is mild punctate epithelial erosion. The physician diagnoses entropion of the right upper eyelid but does not specify the exact etiology in the chart. The patient is scheduled for a surgical repair next week.
Diagnoses:
- H02.001 — Unspecified entropion of right upper eyelid (Primary diagnosis)
Procedure:
- 92012 — Ophthalmological exam, established patient
Scenario 2 — CDI Query: Missing Etiology Specificity
Clinical Vignette: A patient is evaluated for an inverted right upper eyelid. The physician’s assessment states: “Right upper eyelid entropion secondary to severe trachoma scarring.” The coder initially looks at
H02.001based on the term “entropion.”
Action / Outcome:
Because the physician explicitly documented that the entropion is caused by scarring (cicatricial), using the unspecified code H02.001 is inaccurate and represents a loss of clinical specificity.
Corrected ICD-10-CM Coding:
H02.011— Cicatricial entropion of right upper eyelid- Do not code H02.001.
⚠️ Coding Pitfalls and Tips
| Pitfall or Tip | |
|---|---|
| ❌ | Defaulting to Unspecified. Do not use H02.001 if the physician documents a specific cause, such as senile (age-related), spastic, or cicatricial (scarring) entropion. Always review the history and exam for etiology to assign the most specific code from the H02.01- to H02.04- subcategories. |
| ❌ | Mismatched Modifiers. When billing the surgical repair (e.g., 67924), failing to append the correct HCPCS eyelid modifier (-E3 for right upper) that matches the laterality of the diagnosis code (H02.001) will result in a claim denial. |
| ✅ | Code Associated Corneal Damage. If the rubbing lashes have caused a corneal abrasion or ulcer, code the corneal condition additionally (e.g., S05.01XA Injury of conjunctiva and corneal abrasion without foreign body, right eye) to justify the medical necessity of urgent surgical repair. |
| ✅ | Cosmetic vs. Medically Necessary. Entropion repair is almost always medically necessary due to the risk of corneal damage, but precise documentation of the symptoms (pain, tearing, visual disturbance) and physical findings (trichiasis, corneal erosions) is essential to bypass cosmetic surgery edits by payers.^3 |
📚 Sources
1. CMS/NCHS. *ICD-10-CM Official Guidelines for Coding and Reporting, FY2026.* Chapter 7: Diseases of the Eye and Adnexa.2. American Academy of Ophthalmology (AAO). *Basic and Clinical Science Course (BCSC): Ophthalmic Plastic and Reconstructive Surgery.* (Source for pathophysiology and treatment of entropion).
3. CMS/Medicare Administrative Contractors (MACs). *Local Coverage Determinations (LCD) for Blepharoplasty, Blepharoptosis, and Brow Lift.* (Details requirements for medical necessity documentation to distinguish from cosmetic procedures).
4. American Medical Association (AMA). *CPT Professional Edition 2026.* Surgery / Eye and Ocular Adnexa.