Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist performed a pars plana vitrectomy, removing lens fragments from the posterior segment. We looked at 66852, which does describe the removal of the lens material. But the code is under the “Anterior Segment” category in the CPT^® manual. Which code should I use for the posterior segment procedure?

Michigan Subscriber

Answer: Your coding depends on the amount of lens material removed and the method the ophthalmologist used to remove it.

Report 67036 (Vitrectomy, mechanical, pars plana approach), which appears under the “Posterior Segment” heading in the CPT^® manual, if the lens material had dropped to the back of the posterior chamber making a posterior vitrectomy necessary. If the lens material is small and removed by use of the vitrector, no separate code is used for its removal.

If the lens material is large and phacofragmentation is necessary to remove it, report 66850 (Removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration) and 67036 for the pars plana vitrectomy. However, if the lens material is not far from its original position and only a partial posterior vitrectomy is necessary to remove it, report 66852 (Removal of lens material; pars plana approach, with or without vitrectomy), which includes both the vitrectomy and lensectomy.