ICD-10 Code H59.213 – Accidental puncture and laceration of eye and adnexa during an ophthalmic procedure, bilateral (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code H59.213 – Accidental puncture and laceration of eye and adnexa during an ophthalmic procedure, bilateral
What it is
This code identifies an accidental puncture or laceration involving both eyes or nearby adnexal structures during an ophthalmic procedure. It is used when the injury is a documented procedural complication, not the intended surgical effect.
Clinical signs
Clinical features vary; refer to documentation. Typical findings may include a noted perforation, tear, or cut recognized during or after the eye procedure, with bilateral involvement recorded in the operative or postoperative note.
When to use this code
Use H59.213 when the record clearly states that both eyes or adnexa were accidentally punctured or lacerated during an ophthalmic procedure. The documentation should link the injury to the procedure and identify the bilateral nature of the complication. Check documentation if laterality is unclear.
Do not use for
Do not use this code for preexisting eye trauma, planned surgical incisions, or complications not caused by an ophthalmic procedure. If the injury is unilateral or the record does not confirm bilateral involvement, code the documented laterality instead.
Coding tip
Confirm the procedure note and postoperative diagnosis before assigning H59.213.