ICD-10 Code H02.401 – Unspecified ptosis of right eyelid (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code H02.401 – Unspecified ptosis of right eyelid
What it is
This code identifies drooping of the right upper eyelid when the cause or type is not specified. It tells you the condition is on the right side, but documentation does not define a more exact diagnosis.
Clinical signs
Typical findings include a visibly lowered right eyelid that may partially cover the pupil. Clinical features vary; refer to documentation for whether the ptosis is congenital, acquired, or related to another disorder.
When to use this code
Use H02.401 when the record documents right eyelid ptosis but does not name a specific cause, laterality beyond the right side, or subtype. It is appropriate for problem lists, outpatient assessments, or follow-up notes when the diagnosis remains unspecified. Check documentation if another eyelid disorder or neurologic cause is described.
Do not use for
Do not use this code if the chart specifies a different eyelid condition, a left or bilateral ptosis code, or a more detailed cause. Do not assign it when documentation clearly supports a more specific diagnosis.
Coding tip
If the note says only “right ptosis,” code the unspecified right eyelid ptosis unless the provider documents a more specific etiology.