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Coding & Billing
Documenting Vitrectomy and Retinal Detachment Repair
Lolita Jones
Publish Date: February 9, 2008   |  Tags:   Ophthalmology

The significant changes to the vitrectomy and retinal detachment codes will require your physicians to provide stronger documentation.

Vitrectomy
Let's start with vitrectomy. Be sure to document this clinical information in the medical record:

The type of vitrectomy performed:

  • anterior approach
  • posterior/pars plana approach

The instrument(s) used to perform the vitrectomy:

  • mechanical (the use of vitrector, microvit, ocutome or retractor, for example)
  • non-mechanical (the use of Weck-cel sponges and scissors, for example)

The procedure(s) performed:

  • aspiration or release of vitreous
  • cryotherapy
  • discission of vitreous strands
  • drainage of subretinal fluid
  • focal endolaser photocoagulation
  • injection of vitreous substitute
  • internal limiting retinal membrane removal
  • panretinal endolaser photocoagulation
  • preretinal cellular membrane removal
  • removal of lens material/lensectomy
  • retinal detachment repair (specify stage of proliferative vitreoretinopathy and degree of retinal tear if diagnosed)
  • scleral buckling
  • severing of vitreous strands
  • subretinal membrane removal
  • tamponade (air, gas, silicone oil)

Code 67038 has been deleted and replaced with three new codes (67041-67043) that serve to better differentiate the various methodologies and levels of surgical intensity used in vitrectomy procedures involving the retinal membrane.

  • For use of ophthalmic endoscope with 67036, 67039 and 67040-67043, use 66990.
  • For use of vitrectomy in retinal detachment surgery, use 67108 and 67113.

Retinal detachment
Document this clinical information in the medical record when you repair a retinal detachment:

The complexity of specific diagnoses:

  • specify the stage of proliferative vitreoretinopathy (stage C-1, for example)
  • specify the degree of the retinal tear (90 degrees, for example)

The technique(s) used for the repair:

  • cryotherapy
  • diathermy
  • drainage of subretinal fluid
  • focal endolaser photocoagulation
  • membrane peeling (specify as internal limiting membrane, preretinal cellular or subretinal)
  • panretinal endolaser photocoagulation
  • pneumatic retinopexy
  • removal of lens/lensectomy
  • scleral buckling, (specify as initial or repeat buckling procedure)
  • tamponade (air, gas or silicone oil)
  • vitrectomy (specify as initial or repeat vitrectomy procedure)

Code 67113 has been established to report repair of complex retinal detachment that involves a vitrectomy with the removal of a neovascular membrane from the subretinal space. The procedure requires a vitrectomy and a retinotomy. The neovascular membrane is grasped and removed; the retina is approximated to the surface of the choroid and pigment epithelium; and a therapeutic intraocular gas bubble is inserted. Photocoagulation may be applied to the margins of the retinotomy. This procedure is performed less commonly than vitrectomy, pars plana approach, which is reported with codes 67036-67043.

One final note: To report vitrectomy, pars plana approach, other than in retinal detachment surgery, use 67043-67043.

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