ICD-10 Code H02.409 – Unspecified ptosis of unspecified eyelid (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code H02.409 – Unspecified ptosis of unspecified eyelid
What it is
This code identifies drooping of an eyelid when the chart does not specify which eyelid is affected or the cause. Use it when the documentation simply states ptosis and no further detail is available.
Clinical signs
Typical findings include a visibly lowered upper eyelid and possible partial obstruction of the pupil. Clinical features vary; refer to documentation.
When to use this code
Use H02.409 when the provider documents ptosis but does not identify the side, laterality, or etiology. It also fits cases where the record confirms eyelid droop without enough detail for a more specific code. Check documentation if surgery, neurologic disease, or trauma is mentioned.
Do not use for
Do not use this code if the record specifies congenital ptosis, mechanical ptosis, or another defined cause. Also avoid it when laterality is documented and a more specific code is available.
Coding tip
Query for laterality and cause before defaulting to this unspecified code.