Retinopathy of prematurity, stage 5, bilateral

This code signifies the most severe form of retinopathy of prematurity (ROP) affecting both eyes, characterized by total retinal detachment. Stage 5 ROP involves the formation of a retrolental fibrovascular mass, leading to significant vision impairment or blindness. This condition develops in premature infants due to abnormal blood vessel growth in the retina.

Assign this code when documentation confirms bilateral stage 5 ROP, typically diagnosed by an ophthalmologist. This diagnosis is common in infants born extremely prematurely or with very low birth weight who have undergone ophthalmological examination. Supporting documentation will include detailed ophthalmological reports describing the retinal detachment and fibrovascular proliferation in both eyes.

• Ensure documentation explicitly states "bilateral" involvement and "stage 5" to accurately assign this code.
• Do not confuse with less severe stages of ROP (H35.161, H35.162, H35.169) or unilateral involvement.
• Always sequence this code after a code identifying the prematurity or low birth weight, if applicable, to establish the causal link.