Ophthalmology - Retina Surgery & Vitrectomy

Retina Surgery & Vitrectomy

Complex vs. Simple Repair

• 67113 (Complex Repair): Requires specific pathology. Documentation must explicitly state one of the following to justify “complex”:
  • Proliferative vitreoretinopathy (PVR) grade C-1 or greater.
  • Diabetic traction retinal detachment.
  • Retinopathy of prematurity.
  • Giant retinal tear (>90 degrees).
• Mandatory Elements for 67113: Must perform Vitrectomy AND Membrane Peeling. If peeling is not done, you cannot use 67113.

Bundling Alerts (NCCI)

• Lensectomy (66850) with Vitrectomy (67036): Generally bundled.
  • Rule: You cannot bill 66850 separately unless the lens is removed and an IOL is NOT inserted (left aphakic).
  • Exception: If the code descriptor includes “removal of lens” (e.g., 67113), you never bill lensectomy separately.
• Air/Gas/Oil: Tamponade is included in the main vitrectomy codes (67042, 67108, 67113) and is not separately billable.

New Technology (2025)

• 0936T: New Category III code for Photobiomodulation therapy of the retina (single session). Use Modifier 50 for bilateral.
• Subretinal Gene Therapy: HCPCS C9770 covers vitrectomy with subretinal injection (e.g., Luxturna administration). Do not bill standard vitrectomy (67036) for this.

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Here are detailed notes for Retina Surgery & Vitrectomy to add to your reference guide. These focus on the high-frequency audit targets: distinguishing “complex” repairs and handling the lensectomy bundling rules.

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Retina Surgery & Vitrectomy Coding

Core Vitrectomy Codes (Hierarchical)

• 67036: Pars Plana Vitrectomy (PPV) - Basic.
  • Use for: vitreous hemorrhage, simple detachment without PVR, vitreous opacities.
• 67041: PPV + Removal of Preretinal Cellular Membrane.
  • Target: Macular Pucker / Epiretinal Membrane (ERM).
• 67042: PPV + Removal of Internal Limiting Membrane (ILM).
  • Target: Macular Hole, Diabetic Macular Edema (DME).
• 67108: Repair of Retinal Detachment (RD) with Vitrectomy.
  • Includes: Scleral buckle, air/gas exchange, cryo, endolaser, drainage of subretinal fluid.
• 67113: Repair of Complex Retinal Detachment.
  • Mandatory: Must perform Vitrectomy AND Membrane Peeling.

Documentation for 67113 (Complex Repair)

To bill 67113, you must document one of the following conditions to justify “complexity.” Without this, auditors will downcode to 67108.

1. PVR: Proliferative Vitreoretinopathy (Grade C-1 or greater).
2. Diabetic Traction RD: Explicitly state “traction” in the diagnosis.
3. Giant Retinal Tear: Tear greater than 90 degrees.
4. ROP: Retinopathy of Prematurity.

The Lensectomy Bundling Rule (66850 vs. 67036)

• The Rule: Removal of lens material (66850) is generally bundled into Vitrectomy codes (67036, 67108, 67113).
• The Exception (Billable): You may bill 66850 separately only if:
  1. The natural lens is removed; AND
  2. An Intraocular Lens (IOL) is NOT inserted (patient is left aphakic).
• Scenario: If the surgeon removes the lens (66850) and inserts an IOL (66985) during the vitrectomy, 66850 is bundled into the IOL code. You bill 67036 + 66985.

Re-Operation Modifiers (Critical for Retina)

Retina patients often require repeat surgeries. Choosing between 58 and 78 determines if you get paid 100% or ~70%.

Scenario	Modifier	Payment	Global Period
Lesser to Greater: Patient had Pneumatic Retinopexy (67110), failed, now needs Vitrectomy (67108) within global.	-58	100%	Restarts
Staged: Silicone oil placement (Surgery 1) followed by planned removal (Surgery 2).	-58	100%	Restarts
Complication: Patient had Vitrectomy, returns to OR for unplanned repair of wound dehiscence or unrelated bleed.	-78	~70%	No Change
New Problem: Patient had Vitrectomy on Right Eye. Now needs Vitrectomy on Left Eye during global.	-79	100%	New Period

New Technology & Codes (2025/2026)

• 0936T (Category III): Photobiomodulation therapy of the retina (single session).
  • Note: If bilateral, report with Modifier 50.
• C9770: Vitrectomy with subretinal injection of pharmacologic/biologic agent (e.g., gene therapy).
  • Alert: Do not bill generic 67036 for this; use the specific C code.
• 0810T (Category III): Subretinal injection with vitrectomy and retinotomy.

ICD-10 Specificity Checklist

• Diabetic Retinopathy: Must specify if with Traction Detachment (e.g., E11.353 not involving macula vs. E11.352 involving macula).
• Vitreous Hemorrhage: H43.1- (Specify Right, Left, Bilateral).
• PVR: If billing 67113 for PVR, ensure a code from H33.4- (Traction detachment) or H59.81- (Chorioretinal scars/PVR after surgery) is linked.

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