Ophthalmology and Optometry Coding Alert

Question: How can we get paid for a vitrectomy with membrane peeling, especially when it is a difficult case?

South Carolina Subscriber
 
Answer: The code for vitrectomy with membrane peeling is 67038 (vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping). Some of these procedures go on for five hours, and you would be justified in adding modifier -22 (unusual procedural services). But that doesnt necessarily mean you will be paid extra.

Unless you use a lot of special techniques, spend a long time and perform a procedure that is truly difficult, you dont merit additional payment. The key is the operative note.

If you want to pursue extra payment, be prepared to work for it. Modifier -22 will require that you send your claim by paper with additional documentation. You will need to provide the operative report and a cover letter explaining why the procedure was more extensive, and the claim will have to go through review. Be prepared to be patient.

Time is a factor, if the rest of the report explains the work and special techniques in detail that took the extra time.