Retinal neovascularization, unspecified, bilateral

This code describes the abnormal growth of new blood vessels on the retina, affecting both eyes, without further specification of the underlying cause or type. Retinal neovascularization can lead to vision loss due to hemorrhage, fibrosis, or retinal detachment.

Apply this code when documentation indicates retinal neovascularization is present in both eyes, and the specific type (e.g., subretinal, preretinal) or underlying etiology (e.g., diabetic retinopathy, age-related macular degeneration) is not specified. This code is appropriate when the physician has diagnosed neovascularization bilaterally but has not provided more granular detail.

• Avoid using this code if a more specific code for the type or cause of retinal neovascularization (e.g., diabetic retinopathy with neovascularization) is available and documented.
• Ensure the documentation explicitly states "bilateral" or indicates involvement of both eyes; otherwise, use a unilateral or unspecified eye code.
• Query the provider for clarification if the documentation mentions neovascularization but lacks laterality or specific details, to allow for more precise coding.