Retinopathy of prematurity, stage 5, left eye

This code signifies the most severe stage of retinopathy of prematurity (ROP) affecting the left eye, characterized by total retinal detachment and the formation of a retrolental fibrovascular mass. This advanced stage often leads to significant vision impairment or blindness.

Use this code for premature infants diagnosed with stage 5 ROP in their left eye. Documentation should clearly indicate the diagnosis of ROP, the specific stage (stage 5), and laterality (left eye), typically confirmed by ophthalmological examination.

• Ensure the documentation specifies "stage 5" and not an earlier stage of ROP.
• Verify laterality; separate codes exist for the right eye (H35.161) and bilateral involvement (H35.163).
• Code any associated complications, such as blindness, in addition to the ROP stage.