Staphyloma posticum, unspecified eye

This code describes a posterior staphyloma, which is a localized, ectatic thinning of the sclera and choroid, typically occurring at the posterior pole of the eye. This condition results in an outward bulging of the eye wall, often associated with high myopia or degenerative changes.

Use this code when documentation indicates a posterior staphyloma without specifying which eye is affected. This diagnosis is typically made through ophthalmoscopy, B-scan ultrasonography, or optical coherence tomography (OCT). Ensure the medical record clearly states "staphyloma posticum" or "posterior staphyloma" and does not specify laterality.

• Do not use this code if the laterality (right or left eye) is documented; instead, choose the more specific code for the affected eye.
• Consider co-occurring conditions such as high myopia (H44.2x) or other degenerative changes of the globe.
• This code indicates an unspecified eye; if the documentation is unclear, query the provider for clarification on laterality.