Retinopathy of prematurity, stage 4, unspecified eye

This code describes a severe form of retinopathy of prematurity (ROP) where there is a partial retinal detachment, often involving the macula, in an unspecified eye. ROP is an abnormal blood vessel development in the retina of premature infants, and stage 4 indicates significant progression of the disease. This stage can lead to severe vision impairment or blindness if not treated.

Use this code when documentation specifies retinopathy of prematurity, stage 4, and the affected eye is not specified (e.g., "bilateral" or "right/left" is not documented). This diagnosis is typically made by an ophthalmologist during an eye exam of a premature infant. Supporting documentation should include the stage of ROP and the lack of laterality specification.

• Ensure the medical record clearly states "stage 4" ROP; do not assume based on other findings.
• If laterality (right, left, or bilateral) is documented, use the more specific codes (H35.151, H35.152, H35.153).
• Consider sequencing this code after any codes for prematurity or low birth weight, if applicable, as ROP is a complication of prematurity.