Ophthalmology and Optometry Coding Alert

Question:  Our ophthalmologist examined a patient who had recently had retinal repair and had silicon oil inserted in the vitreous cavity. The ophthalmologist found elevated pressure in the patient's eye and removed the silicon oil to correct the problem. I can't find a code for the silicon oil removal.

Illinois Subscriber

Answer: If your ophthalmologist removed the silicon oil by performing a vitrectomy, which is how it's typically done, report 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 silicon 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 silicon oil was planned, and the first procedure is greater than the removal of the silicon, use modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) for the related procedure if it was performed during the postoperative period of the first procedure.