Retinopathy of prematurity, stage 2, bilateral

This code signifies a moderate form of retinopathy of prematurity (ROP) affecting both eyes. Stage 2 ROP is characterized by the presence of a raised, broad, and irregular ridge of fibrovascular tissue at the junction of the vascularized and avascular retina.

Use this code when documentation confirms a diagnosis of Stage 2 ROP in both eyes of a premature infant. This diagnosis is typically made by an ophthalmologist during a retinal examination. The medical record should clearly specify the stage and bilateral involvement.

• Ensure the documentation explicitly states "bilateral" involvement; otherwise, use a unilateral code.
• Verify the specific stage of ROP (Stage 2 in this case) as other stages have distinct codes.
• Always sequence this code after a code for the underlying prematurity or low birth weight, if applicable.