Unspecified retinal detachment with retinal break, bilateral

This code signifies a retinal detachment in both eyes that includes a tear or hole in the retina, but the specific type or cause of the detachment is not documented. It indicates a separation of the neurosensory retina from the underlying retinal pigment epithelium in both eyes, accompanied by a full-thickness defect in the retina.

Apply this code when documentation clearly states bilateral retinal detachment with a retinal break, but lacks further specificity regarding the detachment's etiology (e.g., rhegmatogenous, tractional, exudative). This code is appropriate when the physician notes "bilateral retinal detachment with break, unspecified" or similar language without additional detail.

• Ensure documentation explicitly states "bilateral" and "retinal break" to support this code.
• Avoid using this code if the type of retinal detachment (e.g., rhegmatogenous, tractional) is specified; instead, use a more specific code from the H33.0 or H33.2 subcategories.
• If only one eye is affected, or if the laterality is not documented, a different code should be selected.