Ophthalmology and Optometry Coding Alert

Question: I can't seem to locate a code that describes the removal of silicone oil from the vitreous cavity. Do you have any suggestions, or am I going to have to use an unlisted-procedure code?

OPC Subscriber

Answer: Silicone oil is sometimes used instead of gas to keep the retina attached when long-term support of the retina is required, typically associated with retinal tears and detachments. Removal of the oil, which is necessary because silicone can promote cataracts and glaucoma and/or damage the cornea, usually requires a second surgery at a later date.

Silicone-oil removal is typically performed via a pars plana vitrectomy, code 67036 (Vitrectomy, mechanical, pars plana approach).

Depending on the circumstances and documentation, 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 procedure in which the silicone oil was inserted.

Also, depending on the first procedure performed, the vitrectomy will probably represent a greater procedure following a lesser procedure, which also justifies the use of modifier -58. If the record does not indicate that the removal of the silicone oil was planned, and the first procedure is greater than the removal of the silicone, use modifier -78 (Return to the operating room for a related procedure during the postoperative period) for the related procedure if it was performed during the postoperative period of the first procedure.

Answers to You Be the Coder and Reader Questions provided by Marianne F. Wink, RHIT, compliance analyst/educator with Strong Health Compliance Office in Rochester, N.Y.; and Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.