Ophthalmology and Optometry Coding Alert

Question: When the ophthalmologist drains some of the vitreous gel in tandem with other retinal repair techniques, such as cryotherapy or photocoagulation, to provide better access to the repair, how should we code this?

South Carolina Subscriber

Answer: When the ophthalmologist removes some of the vitreous in addition to repairing a detached retina using heat produced by a laser beam or by freezing the tissues, report 67108 (Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy …). This procedure may include the injection of a gas bubble or silicone oil into the vitreous cavity to help hold the retina in place.

Watch for this: Unlike with a gas bubble, the body cannot absorb silicone oil back into the body. Silicone oil injected into the vitreous cavity is usually removed at a later date, commonly by performing a vitrectomy, for which you’d submit 67036 (Vitrectomy, mechanical, pars plana approach). Depending on the circumstances and timing of the procedure, you may need to use modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period) if the removal procedure was planned at the time of the initial vitrectomy in which the silicone oil was inserted, and the documentation supports this.