Malignant neoplasm of unspecified retina

This code signifies the presence of a cancerous tumor originating in the retina, the light-sensitive tissue at the back of the eye, when the specific laterality (right or left eye) is not documented. It indicates a primary malignancy rather than a metastatic lesion.

Use this code when documentation confirms a primary malignant neoplasm of the retina but does not specify whether it affects the right or left eye. This is appropriate for cases where the physician's notes or pathology report clearly state "malignant neoplasm of retina, unspecified eye."

• Avoid using this code if laterality (right or left eye) is documented; instead, select the more specific C69.21 or C69.22.
• Ensure the documentation confirms a primary malignancy; secondary (metastatic) neoplasms of the retina are coded differently.
• Query the provider for laterality if possible to ensure the highest level of specificity in coding.