Retinopathy of prematurity, stage 4, bilateral

This code describes a severe, bilateral retinal disorder affecting premature infants, characterized by partial or total retinal detachment. It signifies the fourth stage of retinopathy of prematurity (ROP), indicating significant progression and potential for severe vision impairment in both eyes.

Use this code for premature infants diagnosed with stage 4 ROP affecting both eyes. Documentation should clearly specify the diagnosis of ROP, the stage (stage 4), and laterality (bilateral involvement). This code is appropriate when the ophthalmologist's assessment confirms the characteristic features of stage 4 ROP in both eyes.

• Ensure the documentation explicitly states "stage 4" and "bilateral" involvement to support this specific code.
• Do not confuse with codes for unilateral ROP or different stages; laterality and stage are crucial for accurate coding.
• Consider co-reporting with codes for prematurity (P07.xx) and other associated conditions as appropriate.