Retinal detachment with giant retinal tear, bilateral

This code signifies a retinal detachment in both eyes that is specifically caused by a giant retinal tear. A giant retinal tear is a full-thickness tear of the retina extending 90 degrees (three clock hours) or more around the circumference of the globe, leading to the separation of the neurosensory retina from the underlying retinal pigment epithelium. This condition typically results in significant vision loss and requires surgical intervention.

Apply this code when documentation clearly indicates bilateral retinal detachment secondary to a giant retinal tear. This diagnosis is often made during ophthalmological examination, including indirect ophthalmoscopy or fundus photography, revealing the characteristic extensive tear and detached retina in both eyes. Supporting documentation should specify the laterality as bilateral.

• Ensure the documentation explicitly states "giant retinal tear" as the cause of the detachment, not just a general retinal tear.
• Verify laterality is clearly documented as bilateral; avoid using unspecified laterality codes if both eyes are affected.
• Differentiate from other types of retinal detachment (e.g., rhegmatogenous, tractional, exudative) which have distinct ICD-10-CM codes.