Type 2 diab with prolif diab rtnop with macular edema, l eye

This code describes a patient diagnosed with type 2 diabetes mellitus who has developed proliferative diabetic retinopathy (PDR) affecting the left eye. A key component is the presence of macular edema, indicating fluid accumulation in the macula, which is a common cause of vision loss in diabetic retinopathy.

Use this code when documentation clearly states type 2 diabetes with PDR and macular edema specifically in the left eye. This typically occurs in ophthalmology or endocrinology settings where detailed retinal examinations confirm the PDR stage and the presence of macular edema. Supporting documentation includes ophthalmological exam notes, fundus photography, and optical coherence tomography (OCT) scans.

• Always confirm the laterality (left eye) and the specific type of diabetic retinopathy (proliferative) and the presence of macular edema.
• Ensure the documentation specifies "type 2 diabetes mellitus" to differentiate from type 1 or unspecified diabetes.
• Do not use this code if the retinopathy is nonproliferative or if macular edema is absent, even if PDR is present.