Diab with moderate nonp rtnop without macular edema, l eye

This code signifies diabetes mellitus that is a direct consequence of another underlying medical condition, specifically presenting with moderate nonproliferative diabetic retinopathy in the left eye, without any associated macular edema. This indicates a stage of diabetic eye disease where microaneurysms, hemorrhages, and cotton wool spots are present, but new blood vessel growth has not yet occurred, and the macula remains unaffected by swelling.

Use this code when documentation clearly states diabetes due to an underlying condition (e.g., cystic fibrosis, pancreatectomy) and the patient has been diagnosed with moderate nonproliferative diabetic retinopathy affecting only the left eye, with no mention of macular edema. Supporting documentation would include ophthalmology reports detailing fundoscopic findings, retinal imaging, and the specific etiology of the diabetes.

• Always ensure the underlying condition causing the diabetes is also coded, typically as the primary diagnosis, with this code following.
• Verify laterality; this code is specific to the left eye. If both eyes are affected, or the right eye, a different code is required.
• Distinguish carefully between nonproliferative and proliferative retinopathy, and confirm the absence of macular edema, as these distinctions significantly alter the code.