Retinopathy of prematurity, stage 4, left eye

This code signifies a severe form of retinopathy of prematurity (ROP) affecting the left eye, characterized by partial retinal detachment. Stage 4 ROP involves significant tractional forces on the retina, leading to its separation from the underlying choroid. This condition is a complication of premature birth, often requiring surgical intervention to prevent complete blindness.

Use this code when documentation clearly indicates a diagnosis of Stage 4 retinopathy of prematurity specifically in the left eye. This diagnosis is typically made by an ophthalmologist following a dilated fundus examination. Supporting documentation should include details of the retinal detachment and the affected eye.

• Ensure the laterality (left eye) is explicitly documented and matches the code.
• Differentiate from Stage 4 ROP of the right eye (H35.151) or bilateral (H35.153).
• Code any associated complications, such as vitreous hemorrhage or neovascularization, with additional appropriate ICD-10-CM codes.