Retinal micro-aneurysms, unspecified, bilateral

This code signifies the presence of small, localized outpouchings or dilations of retinal capillaries in both eyes, without further specification of their nature or cause. These micro-aneurysms are a common early sign of various retinal vascular diseases, particularly diabetic retinopathy. They represent a weakening of the capillary wall and can lead to leakage and hemorrhage.

Apply this code when documentation indicates retinal micro-aneurysms are present in both eyes, and no further details regarding their type, cause, or associated conditions are provided. This is often used when the micro-aneurysms are an incidental finding or when a more specific diagnosis cannot yet be established. Support for this code includes ophthalmological exam findings, fundus photography, or OCT imaging reports noting bilateral retinal micro-aneurysms.

• Always seek more specific documentation regarding the underlying cause (e.g., diabetes) to code a more precise diagnosis if available.
• Do not use this code if the micro-aneurysms are unilateral; instead, select the appropriate code for the affected eye (H35.041 or H35.042).
• If the micro-aneurysms are part of a more comprehensive diagnosis like nonproliferative diabetic retinopathy, code the specific stage of diabetic retinopathy instead.