J30.1 - Allergic rhinitis due to pollen

Clinical Definition

H40.11x1 is Primary Open-Angle Glaucoma (POAG) in the mild stage. This is a progressive optic neuropathy characterized by increased intraocular pressure causing damage to the optic nerve with corresponding visual field loss. The "mild stage" indicates early disease with minimal optic nerve damage and visual field defects.

Documentation Requirements

• Laterality must be specified:

  • Right eye (H40.1111)

  • Left eye (H40.1112)

  • Bilateral (H40.1113)

• Stage must be explicitly documented as "mild"

• Evidence of:

  • Elevated intraocular pressure readings

  • Optic nerve evaluation findings

  • Visual field test results

• Documentation of open angles on gonioscopy

• Confirmation this is primary (not secondary) glaucoma

Common Synonyms

• "High eye pressure"

• "Wide-angle glaucoma"

• "Chronic glaucoma"

• "Adult-onset glaucoma"

• "Chronic simple glaucoma"

Coding Conflicts

Excludes1:

• Secondary glaucoma (H40.3-, H40.4-, H40.5-, H40.6-)

• Congenital glaucoma (Q15.0)

• Steroid-induced glaucoma (H40.6-)

Scribing.io Automation

The AI scribe automatically identifies:

• Key phrases like "POAG" or "primary open-angle glaucoma"

• Laterality mentions

• Stage descriptors ("mild", "early")

• IOP measurements

• Visual field test results

• Gonioscopy findings
  These are mapped to the appropriate code elements, ensuring accurate documentation for H40.11x1.