Retrolental fibroplasia, left eye

This code describes the presence of retrolental fibroplasia, also known as retinopathy of prematurity (ROP), affecting the left eye. ROP is a proliferative vitreoretinopathy that occurs in premature infants, characterized by abnormal blood vessel growth in the retina, potentially leading to retinal detachment and blindness.

Use this code when documentation specifically indicates retrolental fibroplasia or retinopathy of prematurity affecting the left eye. This diagnosis is typically made by an ophthalmologist during an eye examination of a premature infant. Supporting documentation should include findings such as abnormal retinal vascularization, neovascularization, or evidence of retinal detachment due to ROP in the left eye.

• Always specify the laterality (left, right, or bilateral) when documenting and coding ROP.
• Code any associated complications of ROP, such as retinal detachment (H33.-) or blindness (H54.-), in addition to the ROP code.
• Ensure the medical record clearly distinguishes between active ROP and resolved ROP with sequelae; this code is for active or current retrolental fibroplasia.