Retinopathy of prematurity, unspecified, bilateral

This code signifies an undiagnosed stage or type of retinopathy of prematurity affecting both eyes. Retinopathy of prematurity (ROP) is an abnormal blood vessel development in the retina of premature infants, potentially leading to vision impairment or blindness.

Apply this code when documentation indicates ROP is present in both eyes, but the specific stage or type of ROP has not been determined or is not specified. This is often used for initial diagnoses or when further evaluation is pending.

• Do not use this code if a specific stage of ROP (e.g., Stage 1, Stage 2) is documented for either eye.
• Ensure the medical record explicitly states "bilateral" or indicates involvement of both eyes without further specificity.
• If laterality is not specified, default to unspecified laterality (H35.109) unless bilateral involvement is clearly documented.