Focal chorioretin inflammation of posterior pole, bilateral

This code signifies an inflammatory process affecting both eyes, specifically localized to the chorioretinal tissue at the posterior pole of the globe. This inflammation is focal, meaning it is confined to a distinct area rather than being diffuse. It often presents with visual disturbances due to its proximity to the macula.

Apply this code when documentation clearly indicates bilateral, localized chorioretinal inflammation affecting the posterior pole. This diagnosis is typically made following an ophthalmoscopic examination revealing discrete inflammatory lesions in the fundus of both eyes. Supporting documentation should specify the posterior pole involvement.

• Ensure the documentation explicitly states "bilateral" involvement; otherwise, use the appropriate unilateral code.
• Distinguish from diffuse chorioretinitis or other forms of retinitis that are not focal or located at the posterior pole.
• Look for specific mention of the posterior pole in the ophthalmologist's notes to confirm accurate site specificity.