Vitreous degeneration, bilateral

This code signifies a non-inflammatory deterioration of the vitreous humor affecting both eyes. This degeneration can involve liquefaction (synchysis) or condensation (syneresis) of the vitreous gel, leading to changes in its structure and clarity. It is a common age-related process but can also occur secondary to other ocular conditions.

Use this code when documentation explicitly states vitreous degeneration affecting both the right and left eyes. This diagnosis is typically made during an ophthalmic examination, often noting vitreous opacities, posterior vitreous detachment, or other structural changes. Supporting documentation should include findings from slit-lamp examination or B-scan ultrasonography.

• Ensure the medical record clearly indicates bilateral involvement; if only one eye is affected, a more specific unilateral code should be used.
• Do not confuse vitreous degeneration with vitreous hemorrhage (H43.1-) or other vitreous disorders that have distinct ICD-10-CM codes.
• If the vitreous degeneration is secondary to another condition (e.g., myopia, diabetes), code the underlying condition first, followed by this code.