Retinopathy of prematurity, stage 0, bilateral

This code signifies the earliest stage of retinopathy of prematurity (ROP) affecting both eyes. Stage 0 ROP indicates an immature retina without any abnormal vascular changes, but with the potential to develop into more severe stages. It represents a pre-proliferative state requiring continued monitoring.

Apply this code when documentation confirms a diagnosis of retinopathy of prematurity, specifically noted as Stage 0, in both eyes of a premature infant. This diagnosis is typically made by an ophthalmologist during a screening examination. Supporting documentation will include ophthalmic exam findings detailing the absence of ROP signs beyond retinal immaturity.

• Ensure the documentation explicitly states "Stage 0" and "bilateral" for accurate code assignment.
• Do not use this code if any active ROP stages (Stage 1, 2, 3, 4, or 5) are present in either eye.
• Consider sequencing this code after codes for prematurity or low birth weight, if applicable, to provide a complete clinical picture.