Otolaryngology Coding Alert

‘Keratoconjunctivitis’ note will make the difference.

Sicca syndrome (also known as Sjogren’s syndrome) is a disease that causes extreme dryness in the mouth and eyes. The condition can also lead to dryness in other places that need moisture, such as the nose, throat, and skin.

When you still coded by ICD-9, you had a single catch-all code for sicca syndrome: 710.2. The introduction of ICD-10 brought two codes instead:

• M35.00, Sicca syndrome, unspecified
• M35.01, Sicca syndrome with keratoconjunctivitis.

Documentation: Diagnosing Sjogren’s syndrome involves detecting the features of dryness of the eyes and mouth. Your otolaryngologist determines the dryness of the eyes by testing the eye’s ability to wet a small testing paper strip placed under the eyelid (Schirmer’s test using Schirmer tear test strips). He or she also will support the diagnosis by abnormal findings of a biopsy of salivary-gland tissue. Documentation of the biopsy result will help support the medical necessity for treatment.

If the physician makes note of keratoconjunctivitis, you’ll choose M35.01 rather than M35.00 as the diagnosis.

Coder tips: What do you do when a patient complains of dry eye symptoms yet has no clinical signs? Code the symptoms in the absence of a formal diagnosis. Typical symptoms of sicca syndrome might include eye pain (H57.13, Ocular pain, bilateral), redness of the eye (H57.8, Other specified disorders of eye and adnexa), and epiphora (H04.209, Unspecified epiphora, unspecified lacrimal gland).