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Clinical Definition

Corneal epithelial abrasion is a superficial defect or wound of the corneal surface epithelium, typically caused by mechanical trauma. It represents a disruption of the outermost layer of the cornea without involvement of deeper layers.

Documentation Requirements

• Laterality: Must specify right eye, left eye, or bilateral

• Acuity: Document whether acute or chronic/recurrent

• Cause/Mechanism: Document if known (e.g., contact lens, foreign body, trauma)

• Size/Location: Document extent and specific area of corneal involvement

• Associated Conditions: Note any:

  • Presence/absence of foreign body

  • Associated infection

  • Healing status

  • Pain level

Common Synonyms

• Scratched cornea

• Scratched eye

• Eye scratch

• Corneal scratch

• Surface eye injury

Coding Conflicts

Excludes1:

• Deep corneal injury/laceration

• Chemical burns of cornea

• Corneal ulcer

Excludes2:

• Recurrent corneal erosion

• Contact lens-induced keratitis

Scribing.io Automation

Our AI system automatically identifies:

• Anatomical terms ("cornea", "epithelium")

• Injury descriptors ("abrasion", "scratch")

• Laterality mentions

• Causative factors

• Size descriptions

• Treatment plans

The system flags missing elements and prompts for specific documentation requirements to support medical necessity and proper code assignment.