ICD-10 Code H16.109 – Unspecified superficial keratitis, unspecified eye (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code H16.109 – Unspecified superficial keratitis, unspecified eye
What it is
H16.109 identifies superficial inflammation or injury of the cornea when the affected eye is not specified. Use it when the record confirms superficial keratitis but does not name the laterality.
Clinical signs
Typical findings include eye irritation, redness, tearing, photophobia, and a foreign-body sensation. Clinical features vary; refer to documentation for the exact eye involved and any corneal surface findings.
When to use this code
Use this code when the provider documents superficial keratitis and does not specify right, left, or bilateral eye. It also fits when the note states “unspecified eye” or the laterality cannot be determined from the record. Do not assume laterality from context alone.
Do not use for
Do not use this code if the documentation identifies a specific eye, since a laterality-specific code is more accurate. Check documentation if the condition is deeper corneal disease, conjunctivitis, or another diagnosis.
Coding tip
Verify both the diagnosis and laterality in the provider note before assigning H16.109.