Retinopathy of prematurity, stage 2, unspecified eye

This code signifies a specific stage of retinopathy of prematurity (ROP), a disease affecting the eyes of premature infants. Stage 2 ROP is characterized by the development of a raised, broad, and irregular ridge of fibrovascular tissue at the junction of the vascularized and avascular retina. This stage indicates a moderate progression of the disease.

This code is used when a premature infant is diagnosed with Stage 2 ROP, and the specific eye affected (right or left) is not documented or is unknown. Documentation should clearly state "retinopathy of prematurity, stage 2" and either lack laterality or explicitly state "unspecified eye."

• Ensure the documentation specifies "stage 2" and not another stage of ROP.
• Only use this code when laterality is truly unspecified; if right or left eye is documented, use the more specific codes (H35.131 or H35.132).
• Consider any associated conditions or complications of prematurity that may also need to be coded.