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By: Lolita Jones
Published: 2/9/2008
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:
The instrument(s) used to perform the vitrectomy:
The procedure(s) performed:
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.
Retinal detachment
Document this clinical information in the medical record when you repair a retinal detachment:
The complexity of specific diagnoses:
The technique(s) used for the repair:
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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