In simple words: This code describes type 1 diabetes, a condition where the body doesn't make enough insulin, leading to high blood sugar. It also indicates mild damage to the blood vessels in the retina of the eye due to diabetes. The central part of the retina (macula) is not affected.

Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy (NPDR) is a chronic autoimmune disease characterized by the destruction of pancreatic beta cells, resulting in insufficient insulin production and high blood glucose levels. This uncontrolled hyperglycemia gradually damages the retinal blood vessels, but without significant new blood vessel growth (proliferative retinopathy).NPDR involves retinal lesions, including microaneurysms, hemorrhages, and intraretinal microvascular abnormalities, without macular edema.

Example 1: A patient with established type 1 diabetes presents with blurred vision. An ophthalmologic exam reveals microaneurysms and dot hemorrhages in all four quadrants of the retina, consistent with mild NPDR.There is no macular edema. , A patient with type 1 diabetes undergoes a routine eye exam. The ophthalmologist identifies mild NPDR without macular edema. , A teenager diagnosed with new-onset type 1 diabetes several weeks prior presents to the ER with nausea and excessive thirst. During the course of the workup, an ophthalmology consult is ordered given their diabetes diagnosis. Ophthalmology assesses the patient and documents Mild NPDR without macular edema.

Documentation should include the type of diabetes, the presence and severity of retinopathy (mild, moderate, or severe), the presence or absence of macular edema, and the laterality (right, left, bilateral, or unspecified).Eye exam findings, such as microaneurysms and hemorrhages, should be documented. Supporting diagnostic tests, such as HbA1c and ophthalmoscopy results, should also be included.