67015

CPT 67015: Aspiration or Release of Vitreous, Subretinal or Choroidal Fluid

Code Classification

• CPT Code: 67015
• Full Description: Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy)
• Category: Surgery
• Section: Eye and Ocular Adnexa (65091-68899)
• Subsection: Posterior Segment (67005-67299)
• Type: Surgical Procedure - Diagnostic/Therapeutic
• Global Period: 10 days
• Bilateral Indicator: Bilateral procedure (modifier 50 applicable)
• Anesthesia: Typically local with monitored anesthesia care (MAC) or topical

Procedure Description

CPT 67015 describes a limited surgical procedure to aspirate (remove) or release fluid from the vitreous cavity, subretinal space, or choroidal space using a pars plana approach with posterior sclerotomy. This is a minimally invasive procedure typically performed for diagnostic purposes (obtaining vitreous samples for culture/analysis) or therapeutic purposes (relieving pressure, removing blood).

Clinical Purpose

Diagnostic Indications:

• Endophthalmitis workup (most common):
  • Obtaining vitreous sample for culture and sensitivity
  • Gram stain of vitreous material
  • Identifying causative organism
  • Guiding antibiotic selection
• Suspected intraocular lymphoma: Vitreous biopsy for cytology
• Uveitis of unknown etiology: Vitreous analysis for inflammatory markers
• Suspected infectious uveitis: PCR testing for viral/bacterial/fungal pathogens

Therapeutic Indications:

• Vitreous hemorrhage: Limited aspiration to clear visual axis
• Intravitreal gas/silicone oil removal: Releasing retained gas bubble
• Subretinal fluid drainage: In retinal detachment repair (adjunct to scleral buckle)
• Choroidal fluid drainage: Suprachoroidal hemorrhage evacuation
• Vitreous debris removal: Limited cleanup without full vitrectomy

Anatomical Approach

Pars Plana Location:

• Located 3.0-4.0mm posterior to the limbus
• Avascular zone between ciliary body and retina
• Safe entry point minimizing damage to:
  • Lens (anteriorly)
  • Retina (posteriorly)
  • Iris and ciliary body

Posterior Sclerotomy:

• Surgical incision through:
  1. Conjunctiva
  2. Sclera
  3. Choroid
  4. Pars plana
  5. Into vitreous cavity

Procedure Technique

Pre-Procedure:

1. Informed consent obtained
2. Topical or local anesthesia administered
3. Povidone-iodine prep (5-10% solution)
4. Sterile draping of operative field
5. Lid speculum placement
6. Patient positioned (typically supine)

Surgical Steps:

1. Measurement and marking:

   • Mark pars plana entry site 3.5-4.0mm from limbus
   • Avoid area of obvious pathology if visible

2. Sclerotomy creation:

   • Small conjunctival peritomy (optional)
   • 20-23 gauge needle or MVR blade
   • Oblique tunnel through sclera into vitreous cavity
   • Single port entry (unlike full 3-port vitrectomy)

3. Aspiration:

   • For diagnostic tap:
     • Attach tuberculin syringe to needle
     • Gentle aspiration of 0.2-0.5mL undiluted vitreous
     • Sample immediately transferred to culture media
     • May obtain multiple samples (aerobic, anaerobic, fungal cultures)
   • For therapeutic drainage:
     • Larger gauge needle or cannula
     • Passive drainage or active aspiration
     • Monitor intraocular pressure

4. Injection (if applicable):

   • Intravitreal antibiotics often given immediately after tap
   • Typically vancomycin + ceftazidime or amikacin
   • Separate injection procedure (code 67028)

5. Closure:

   • Self-sealing sclerotomy (small gauge)
   • May place single suture if needed (rare)
   • Conjunctiva repositioned
   • Antibiotic ointment applied
   • Eye patch/shield (optional)

Post-Procedure:

• Immediate IOP check
• Observation for complications (30-60 minutes)
• Topical antibiotics prescribed
• Follow-up scheduled (24-48 hours)

What’s Included in CPT 67015

The code includes:

• Pre-operative assessment and marking
• Local/topical anesthesia administration
• Sterile preparation and draping
• Creation of posterior sclerotomy (pars plana approach)
• Aspiration or release of fluid (vitreous, subretinal, or choroidal)
• Closure of sclerotomy site
• Immediate post-operative care in facility
• Post-operative visits within 10-day global period
• Unilateral procedure (one eye)

Does NOT include:

• Intravitreal injection of medications (code 67028 separately)
• Full pars plana vitrectomy (codes 67036-67043)
• Scleral buckle or retinal detachment repair (codes 67107-67113)
• Extended vitrectomy procedures
• Bilateral procedures (use modifier 50)

Important Distinction: 67015 vs Full Vitrectomy

67015 (This code):

• Limited procedure: Simple aspiration/tap
• Minimal instrumentation: Needle or small cannula
• No vitrectomy machine: Manual aspiration
• Brief procedure: 5-15 minutes
• Diagnostic focus: Culture/cytology samples
• Single port: One entry site
• Examples: Vitreous tap for endophthalmitis, limited hemorrhage aspiration

67036-67043 (Full vitrectomy):

• Complex procedure: Mechanical vitreous removal
• Vitrectomy machine: Powered instrumentation
• Extended surgery: 45-120+ minutes
• Therapeutic focus: Complete vitreous removal/retinal surgery
• Multi-port: Typically 3 ports (infusion, light, cutter)
• Examples: Diabetic vitreous hemorrhage, retinal detachment, macular hole

wRVU (Work Relative Value Units)

2025 Medicare Physician Fee Schedule Values:

Facility Setting (Hospital, ASC)

• Work RVU: 6.19
• Practice Expense RVU: 11.72
• Malpractice RVU: 1.38
• Total RVU: 19.29
• National Payment (2025): ~$643.75(conversionfactor$33.37)

Non-Facility Setting (Office, Surgical Suite)

• Work RVU: 6.19 (same)
• Practice Expense RVU: 26.98 (significantly higher)
• Malpractice RVU: 1.38
• Total RVU: 34.55
• National Payment (2025): ~$1,153.03

Key Points:

• Work RVU represents physician effort, skill, time, and stress
• Higher practice expense in office setting due to:
  • Surgical equipment and supplies
  • Facility overhead
  • Staff costs
  • Sterilization requirements
• Geographic adjustment varies by locality (GPCI)
• Global period: 10 days (includes related post-op visits)

Relative Value Breakdown

• Pre-service time: 15 minutes
  • Patient positioning
  • Anesthesia setup
  • Sterile prep
• Intra-service time: 25 minutes
  • Actual surgical procedure
  • Includes aspiration and immediate closure
• Post-service time: 10 minutes
  • Immediate post-op check
  • Documentation
  • Orders
• Total physician time: 50 minutes
• Intensity/Complexity: High (intraocular surgery)

Global Period Details

• 10-day global period: Includes all related care for 10 days post-op
• Included in global:
  • Same-day pre-operative evaluation
  • Immediate post-op care
  • All post-op visits within 10 days for normal recovery
  • Complications related to procedure within 10 days
• NOT included (bill separately):
  • Unrelated E/M services (modifier 24)
  • Return to OR for complications (modifier 78)
  • Staged procedures (modifier 58)
  • Procedures on other eye (modifier 79)

Assistant Surgeon Information

Assistant Surgeon Payability: GENERALLY NOT PAYABLE

• CMS Status Indicator: “1” = Statutory payment restriction for assistants at surgery
• Typical Assistant Surgeon Payment: 0% (not covered by Medicare)
• Rationale: Procedure does not typically require assistant surgeon

Medicare Policy:

• Medicare does NOT typically pay for assistant surgeon for 67015
• Procedure can be performed safely by single surgeon
• Not on approved list for automatic assistant surgeon payment

Exceptions (Rare):

• Modifier -80: Assistant surgeon - typically denied unless unusual circumstances documented
• Modifier -81: Minimum assistant surgeon - not applicable
• Modifier -82: Assistant surgeon when qualified surgeon not available - may be approved in remote areas with documentation
• Teaching physician scenario: Resident assisting (no separate payment, bundled)

Commercial Payers:

• Most follow Medicare guidelines (no assistant payment)
• Some may allow assistant in hospital setting with prior authorization
• Required documentation:
  • Medical necessity for assistant
  • Complexity requiring second surgeon
  • Patient factors (severe inflammation, difficult anatomy)

Co-Surgeon (Modifier -62):

• Not typically applicable to 67015
• May apply if two surgeons performing bilateral simultaneous procedures
• Each surgeon must document separate roles

Team Surgery (Modifier -66):

• Not applicable to 67015 (too simple for team approach)

Who Typically Performs:

• Ophthalmologist (vitreoretinal specialist or comprehensive)
• Solo surgeon
• May have surgical assistant/scrub tech (not billable as co-surgeon)

HCC Information

HCC Status: NOT APPLICABLE (Procedure Code)

Important Note: HCC (Hierarchical Condition Category) codes apply only to ICD-10 diagnosis codes, NOT to CPT procedure codes. CPT 67015 is a procedure code used for billing services rendered.

However, Common Diagnosis Codes Used WITH 67015 May Map to HCC:

HCC 124 - Exudative Macular Degeneration:

• H35.32- (Exudative age-related macular degeneration)
• When 67015 performed for subretinal fluid drainage

HCC 19 - Diabetes with Acute Complications:

• E11.351- (Type 2 diabetes with proliferative diabetic retinopathy)
• When 67015 performed for diabetic vitreous hemorrhage

HCC 18 - Diabetes with Chronic Complications:

• E11.329- (Type 2 diabetes with mild nonproliferative diabetic retinopathy)
• When related to diabetic eye disease

Non-HCC Conditions Commonly Associated with 67015:

• H44.001 (Endophthalmitis) - Most common indication for 67015
• H43.1- (Vitreous hemorrhage)
• H33.0- (Retinal detachment with retinal break)
• H31.4- (Choroidal detachment)

Risk Adjustment Considerations

For Risk Adjustment Purposes:

1. The diagnosis codes used to justify 67015 may affect HCC coding
2. Post-procedure complications that develop may map to HCCs
3. Underlying conditions (diabetes, AMD) should be coded when present
4. Document all comorbidities affecting surgical risk

Example:

• Patient with diabetes (E11.351-) undergoes 67015 for vitreous hemorrhage
• Diabetes code maps to HCC 19
• Proper documentation of diabetes severity affects RAF score
• 67015 procedure code itself does not affect HCC, but diagnosis does

MS-DRG Information

MS-DRG Assignment: APPLICABLE FOR INPATIENT PROCEDURES

CPT 67015 performed as an inpatient or observation procedure may contribute to MS-DRG assignment, though this procedure is most commonly performed on an outpatient basis.

Primary MS-DRG Assignments

When Performed as Inpatient Procedure:

MS-DRG 113: Orbital Procedures with CC/MCC

• Geometric Mean LOS: 2.8 days
• Relative Weight: 1.8563 (FY2025)
• Arithmetic Mean LOS: 3.7 days
• Description: Intraocular surgical procedures with complications/comorbidities

MS-DRG 114: Orbital Procedures without CC/MCC

• Geometric Mean LOS: 1.5 days
• Relative Weight: 1.1837
• Arithmetic Mean LOS: 1.9 days
• Description: Intraocular surgical procedures without complications

DRG Assignment Factors

Factors Influencing DRG:

1. Principal Diagnosis: The condition necessitating admission

   • H44.001 (Endophthalmitis) - most common for 67015
   • H43.1- (Vitreous hemorrhage)
   • H33.0- (Retinal detachment)

2. Secondary Diagnoses - MCC (Major Complications):

   • A41.- (Sepsis)
   • I50.21 (Acute systolic heart failure)
   • J96.0- (Acute respiratory failure)
   • N17.- (Acute kidney failure)

3. Secondary Diagnoses - CC (Complications):

   • E11.65 (Type 2 diabetes with hyperglycemia)
   • I50.9 (Heart failure, unspecified)
   • J44.1 (COPD with acute exacerbation)
   • N18.3- (CKD stage 3)

4. OR Procedure Performed: Yes (67015 is an OR procedure)

5. Patient Age and Sex: Minor factor in DRG assignment

Typical Clinical Scenarios and DRG Assignment

Scenario 1: Endophthalmitis (Most Common)

• Principal Dx: H44.001 (Endophthalmitis)
• Procedure: 67015 (Vitreous tap)
• Often with: 67028 (Intravitreal injection)
• No CC/MCC: MS-DRG 114
• With CC: MS-DRG 113
• With MCC: MS-DRG 113 (higher payment)

Scenario 2: Diabetic Vitreous Hemorrhage

• Principal Dx: H43.1- (Vitreous hemorrhage)
• Secondary Dx: E11.351- (Diabetic retinopathy)
• Procedure: 67015
• No other CC/MCC: MS-DRG 114
• With diabetic complications: MS-DRG 113

Scenario 3: Traumatic Hyphema/Hemorrhage

• Principal Dx: S05.1XXA (Contusion of eyeball)
• Procedure: 67015
• No CC/MCC: MS-DRG 114

Outpatient Setting (Most Common for 67015)

Ambulatory Payment Classification (APC):

• APC 5493: Level 3 Anterior Segment Eye Procedures
• Approximate payment: $1,200-$1,500 (varies by locality)
• Outpatient facility fee separate from professional fee

Office-Based Setting:

• Paid under Medicare Physician Fee Schedule
• No separate facility fee
• Higher practice expense RVU compensates for overhead

POA (Present on Admission) Indicator

Critical for DRG Payment:

• POA = Y (Yes): Condition present on admission

  • Standard payment
  • Not considered hospital-acquired complication

• POA = N (No): Condition developed after admission

  • May affect payment if considered HAC (Hospital-Acquired Condition)
  • If 67015 is for postoperative endophthalmitis: potential payment penalty
  • May trigger quality review

Important POA Scenarios:

1. Endophthalmitis on admission → POA = Y (full payment)
2. Post-cataract surgery endophthalmitis (same admission) → POA = N (potential penalty)
3. Vitreous hemorrhage on admission → POA = Y

Code Tree / Hierarchy

CPT Section Structure

Surgery (10004-69990)
└── Eye and Ocular Adnexa (65091-68899)
    └── Posterior Segment (67005-67299)
        ├── Vitreous (67005-67043)
        │   ├── 67005: Removal of vitreous, anterior approach (open sky technique or limbal incision)
        │   ├── 67010: Removal of vitreous, anterior approach (partial vitrectomy), endo-ocular
        │   ├── 67015: Aspiration/release vitreous, subretinal, choroidal fluid, pars plana ◄ THIS CODE
        │   ├── 67025: Injection of vitreous substitute, pars plana or limbal approach
        │   ├── 67027: Implantation of intravitreal drug delivery system
        │   ├── 67028: Intravitreal injection of pharmacologic agent
        │   ├── 67030: Discission of vitreous strands (without removal), pars plana approach
        │   ├── 67031: Severing of vitreous strands, vitreous face adhesions, sheets, membranes
        │   ├── 67036: Vitrectomy, mechanical, pars plana approach (partial)
        │   ├── 67039: Vitrectomy with focal endolaser photocoagulation
        │   ├── 67040: Vitrectomy with endolaser panretinal photocoagulation
        │   ├── 67041: Vitrectomy with removal of preretinal cellular membrane
        │   ├── 67042: Vitrectomy with removal of internal limiting membrane
        │   └── 67043: Vitrectomy with removal of subretinal membrane
        └── Retina or Choroid (67101-67229)

Related Procedure Codes

67015: Aspiration/release vitreous/subretinal/choroidal fluid ◄ THIS CODE
├── Related diagnostic procedures:
│   ├── 67028: Intravitreal injection (commonly performed with 67015)
│   ├── 92235: Fluorescein angiography (pre-operative diagnostic)
│   └── 76514: Ophthalmic ultrasound, B-scan (pre-operative imaging)
├── More extensive procedures:
│   ├── 67036: Partial pars plana vitrectomy (more extensive than 67015)
│   ├── 67107: Repair of retinal detachment with scleral buckle
│   └── 67108: Repair of retinal detachment with vitrectomy
└── Alternative approaches:
    ├── 67005: Anterior approach vitreous removal
    └── 67010: Anterior approach partial vitrectomy

Includes

CPT 67015 INCLUDES all of the following services:

Pre-Operative Services (Same Day)

• Pre-operative assessment and documentation
• Informed consent discussion
• Patient positioning and preparation
• Eye prep with antiseptic (povidone-iodine)
• Sterile draping
• Local/topical anesthesia administration (if performed by surgeon)

Intra-Operative Services

• Surgical approach planning and marking
• Creation of posterior sclerotomy via pars plana approach
• Aspiration of vitreous fluid using needle/cannula
• OR release of subretinal fluid
• OR release of choroidal fluid
• Multiple aspirations during same session (if needed)
• Closure of sclerotomy site (suture if needed)
• Application of antibiotic ointment
• Application of eye patch/shield

Post-Operative Services (Within 10-Day Global Period)

• Immediate post-operative examination
• Post-operative medications prescribed
• All follow-up visits within 10 days related to normal recovery
• Management of normal post-operative course
• Suture removal (if applicable)

Bilateral Procedures

• If both eyes treated same session: Bill 67015 with modifier 50
• Each eye is separate surgical field
• Documentation must support bilateral medical necessity

Multiple Samples

• Multiple vitreous aspirations during same session
• Samples for different culture media (aerobic, anaerobic, fungal)
• All included in single code (do not bill 67015 × 2)

Excludes

Do NOT Report 67015 With (Same Session, Same Eye):

More Extensive Vitrectomy Procedures (Mutually Exclusive):

• 67036: Vitrectomy, mechanical, pars plana approach
  • If full vitrectomy performed, use 67036, NOT 67015
  • 67036 includes any diagnostic aspiration
• 67039-67043: Vitrectomy with additional procedures
  • These include vitreous removal as part of more complex surgery
• 67005, 67010: Anterior approach vitreous removal
  • Different surgical approach

When Full Vitrectomy is Performed:

• If procedure begins as 67015 but converts to full vitrectomy (67036)
• Code only the more extensive procedure (67036)
• Document reason for conversion

Report Separately (When Appropriate):

Different Eye (Modifier 79):

• Can perform 67015 on one eye and different procedure on fellow eye
• Use modifier 79 if within global period of another procedure

Intravitreal Injection (67028):

• May be reported together with modifier 59 or XS
• Common scenario: Vitreous tap (67015) followed immediately by intravitreal antibiotics (67028)
• Must be clearly documented as separate procedures
• Example coding: 67015, 67028-59

Scleral Buckle/Retinal Detachment Repair:

• 67107-67113: May be reported together if subretinal fluid drainage (67015) is performed as part of retinal detachment surgery
• Use modifier 51 (multiple procedures) or 59 (distinct procedural service) as appropriate
• Document separately in operative report

Imaging Studies:

• 92235: Fluorescein angiography (different date)
• 76514: Ophthalmic B-scan ultrasound (pre-operative)
• Can be performed same day with modifier 59 if documented as separate service

E/M Services:

• 99212-99215: Office visits (use modifier 25 if significant separate E/M)
• 99221-99223: Initial hospital care (same day as procedure - use modifier 25)
• E/M must be above and beyond pre-operative assessment

Bundled Services (Included in 67015):

These are NOT separately billable:

• Local anesthesia administered by surgeon
• Sterile supplies and drapes
• Needle/cannula used for aspiration
• Sutures for closure (if needed)
• Antibiotic ointment
• Eye patch/shield
• Post-operative follow-up within 10 days (normal care)

Modifiers

Commonly Used Modifiers with 67015:

Laterality Modifiers:

• -LT (Left Eye): Specify left eye treated

  • Use when billing unilateral procedure
  • Required by many payers for accurate tracking

• -RT (Right Eye): Specify right eye treated

  • Use when billing unilateral procedure
  • Required by many payers

• -50 (Bilateral Procedure): Both eyes treated same session

  • Payment: Typically 150% of unilateral fee (varies by payer)
  • Medicare: 150% payment (100% for first eye, 50% for second)
  • Must document medical necessity for bilateral procedures
  • Example: Bilateral endophthalmitis (rare but possible)

Procedural Modifiers:

• -51 (Multiple Procedures): When performed with other procedures same session

  • Usually applied automatically by payer
  • Secondary procedure paid at reduced rate (typically 50%)
  • Not used with bilateral modifier 50

• -59 (Distinct Procedural Service): Unbundling when appropriate

  • Use when 67015 performed with procedures that typically bundle
  • Must document why procedures are separate
  • Example: 67015 for diagnostic tap, then separate 67028 for treatment injection
  • Consider using more specific X-modifiers (XE, XS, XP, XU)

X-Modifiers (More Specific Than -59):

• -XE (Separate Encounter): Different encounter same day
• -XS (Separate Structure): Different anatomical site (e.g., different eye)
• -XP (Separate Practitioner): Different practitioner
• -XU (Unusual Non-Overlapping Service): Unusual circumstances

Reduced/Discontinued Service Modifiers:

• -52 (Reduced Services): Procedure partially completed

  • Example: Unable to obtain adequate vitreous sample due to dense hemorrhage
  • Document reason for incomplete procedure
  • Reduce charge accordingly
  • Payment typically reduced 50% or more

• -53 (Discontinued Procedure): Stopped due to patient wellbeing

  • Example: Patient develops cardiac arrhythmia, procedure aborted
  • Document medical necessity for discontinuation
  • Payment varies (0-50%)

Global Period Modifiers:

• -24 (Unrelated E/M During Post-Op Period): E/M unrelated to surgery

  • Use when seeing patient for unrelated issue within 10-day global
  • Must document unrelated nature
  • Example: Patient returns for diabetes management (unrelated to eye surgery)

• -25 (Significant, Separately Identifiable E/M Same Day): E/M same day as procedure

  • Use when significant E/M performed beyond pre-operative assessment
  • Must exceed usual pre-operative work
  • Document separately in chart

• -58 (Staged Procedure During Post-Op Period): Planned additional procedure

  • Use when planned return to OR within global period
  • Example: Initial vitreous tap, then planned vitrectomy 5 days later
  • Starts new global period

• -78 (Return to OR for Complication): Unplanned return within global period

  • Use for complications requiring surgery
  • Example: Re-aspiration needed due to reaccumulation
  • No new global period (continues original)

• -79 (Unrelated Procedure During Post-Op Period): Different procedure

  • Use when completely unrelated procedure needed
  • Example: Cataract surgery on fellow eye during global period
  • Starts new global period

Assistant Surgeon Modifiers (Rarely Applicable):

• -80 (Assistant Surgeon): Usually not paid for 67015
• -81 (Minimum Assistant Surgeon): Not applicable
• -82 (Assistant When Qualified Surgeon Not Available): Rarely justified

Anesthesia Modifiers:

• -47 (Anesthesia by Surgeon): Not typically used (separate anesthesia usually not needed)
• General anesthesia billed separately by anesthesiologist if needed

Medical Necessity & Coverage

Medicare Coverage Criteria

Covered Indications:

1. Endophthalmitis (Most Common)

• H44.001-H44.003 (Purulent endophthalmitis)
• H44.011-H44.013 (Panophthalmitis)
• Medical necessity: Obtaining culture to guide antibiotic therapy
• Typically covered without prior authorization (emergent)

2. Vitreous Hemorrhage

• H43.1- (Vitreous hemorrhage)
• Medical necessity: Diagnostic sampling or limited therapeutic drainage
• Note: Extensive hemorrhage requiring significant removal → use 67036 instead

3. Suspected Intraocular Lymphoma

• C85.9 (Non-Hodgkin lymphoma, unspecified)
• H30.9 (Chorioretinitis, unspecified)
• Medical necessity: Vitreous biopsy for cytology/flow cytometry

4. Subretinal Fluid Drainage

• H33.0- (Retinal detachment with retinal break)
• H31.4- (Choroidal detachment)
• Medical necessity: Adjunct to retinal reattachment surgery
• Often performed with scleral buckle (67107)

5. Uveitis of Unknown Etiology

• H20.9 (Unspecified iridocyclitis)
• H30.9 (Chorioretinitis, unspecified)
• Medical necessity: Diagnostic workup for infectious vs non-infectious cause

6. Suprachoroidal Hemorrhage

• H31.2- (Hereditary choroidal dystrophy) - if hemorrhagic
• Medical necessity: Drainage of suprachoroidal blood

Frequency Limitations

Medicare Guidelines:

• No specific frequency limit (based on medical necessity)
• Repeated procedures require documentation of:
  • Failed initial therapy
  • Recurrence of condition
  • New indication

Commercial Payers:

• Typically follow Medicare guidelines
• May require prior authorization for repeat procedures within 30 days
• Document medical necessity clearly

Prior Authorization

Generally NOT Required For:

• Emergency endophthalmitis evaluation
• Acute vitreous hemorrhage
• Trauma-related indications

May Require Prior Authorization:

• Elective drainage procedures
• Repeat procedures within short timeframe
• Some commercial payers require PA for all surgical procedures

Documentation Requirements

Operative Report Must Include:

1. Indication: Clear diagnosis requiring procedure
2. Pre-operative assessment:
   • Visual acuity
   • Intraocular pressure
   • Fundus examination findings (if visible)
3. Anesthesia: Type and administration
4. Surgical approach:
   • Eye (right/left)
   • Entry site location (pars plana distance from limbus)
   • Gauge of needle/cannula
5. Procedure details:
   • Amount and appearance of aspirated material
   • Where samples sent (microbiology, pathology, cytology)
   • Any difficulties encountered
6. Closure: How sclerotomy closed
7. Immediate post-op:
   • IOP check
   • Any complications
8. Post-operative plan: Follow-up timing

For Culture Specimens:

• Document samples obtained
• List culture media inoculated
• Specify tests ordered (Gram stain, cultures, PCR, cytology)

Coding Guidelines

Correct Coding Initiative (CCI) Edits

Column 1/Column 2 Edits:

• 67015 is Column 1 (comprehensive procedure)
• Cannot be billed with certain Column 2 codes without modifier

Common Bundled Codes (Column 2):

• 92020: Gonioscopy (included in pre-operative assessment)
• 67005: Anterior vitreous removal (different approach, but may be bundled)

Can Be Billed Together With Modifier 59:

• 67028: Intravitreal injection (distinct from diagnostic tap)
• 67107-67113: Retinal detachment repair (if 67015 is adjunctive drainage)

Billing Rules

1. Unilateral vs Bilateral

• Unilateral: 67015-RT or 67015-LT
• Bilateral: 67015-50 (both eyes same session)
• Never bill: 67015-RT AND 67015-LT separately (use -50 instead)

2. Same Day as Other Procedures

• With injection (67028): Use modifier 59 on 67028
• With vitrectomy (67036): Bill only 67036 (includes tap)
• With retinal detachment repair: May bill both with modifier

3. Converting from 67015 to 67036

• If procedure starts as simple tap but requires full vitrectomy
• Bill only 67036 (more extensive procedure)
• Document reason for conversion in operative report

4. Multiple Attempts Same Session

• Only one unit of 67015
• Do not bill 67015 × 2 even if multiple taps performed
• All attempts same session included in single code

5. Bilateral Procedures

• Use modifier 50
• Payment: 150% of unilateral fee (100% + 50%)
• Must document medical necessity for both eyes

6. Repeat Procedure (Different Date)

• Outside global period: No modifier needed
• Within 10-day global period:
  • If related to original procedure: Included (no additional payment)
  • If complication requiring return to OR: Modifier 78
  • If staged/planned procedure: Modifier 58
  • If unrelated: Modifier 79

7. Assistant Surgeon

• Generally not payable
• If claimed, document unusual circumstances
• Use modifier 80, 81, or 82 as appropriate

8. Incomplete Procedure

• Modifier 52 (reduced services)
• Document reason incomplete
• Reduce charge proportionally

Coding Examples

Example 1: Acute Postoperative Endophthalmitis

Scenario: 68-year-old female 5 days post-cataract surgery presents with severe pain, decreased vision, and hypopyon in right eye. Diagnosed with acute endophthalmitis. Undergoes vitreous tap for culture and receives intravitreal vancomycin and ceftazidime immediately after tap.

Operative Report Summary: “Vitreous tap performed via pars plana approach 3.5mm posterior to limbus using 23-gauge needle. 0.3mL undiluted vitreous obtained and sent for aerobic, anaerobic, and fungal cultures with Gram stain. Following tap, patient received intravitreal vancomycin 1mg/0.1mL and ceftazidime 2.25mg/0.1mL via separate injections.”

Coding:

• CPT:
  • 67015-RT (Vitreous aspiration, right eye)
  • 67028-RT-59 (Intravitreal injection, distinct service)
• Diagnosis:
  • H44.001 (Unspecified purulent endophthalmitis, right eye)
  • H59.41 (Inflammation following cataract surgery)
  • T81.4XXA (Infection following a procedure, initial encounter)
• POA: Y (present on admission)
• Place of Service: 22 (Hospital outpatient) or 24 (ASC)
• Modifiers Explained:
  • -RT: Right eye
  • -59 on 67028: Distinct procedural service (injection separate from diagnostic tap)

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Example 2: Bilateral Endogenous Endophthalmitis (Rare)

Scenario: 55-year-old diabetic male with MRSA bacteremia develops bilateral endogenous endophthalmitis. Undergoes bilateral vitreous taps for culture confirmation.

Coding:

• CPT: 67015-50 (Bilateral vitreous aspiration)
• Diagnosis:
  • A41.02 (Sepsis due to MRSA) - principal diagnosis
  • H44.003 (Unspecified purulent endophthalmitis, bilateral)
  • E11.65 (Type 2 diabetes with hyperglycemia)
  • B95.62 (MRSA as cause of infection)
• POA: All Y
• Place of Service: 22 (Hospital outpatient) or 21 (Inpatient if admitted for sepsis)
• Payment: 150% of unilateral fee
• MS-DRG (if inpatient): 870-872 (Septicemia series, depending on MCC/CC)

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Example 3: Vitreous Hemorrhage - Limited Aspiration

Scenario: 72-year-old with diabetic vitreous hemorrhage obscuring visual axis. Limited vitreous tap performed to clear central vision without full vitrectomy.

Coding:

• CPT: 67015-LT
• Diagnosis:
  • H43.12 (Vitreous hemorrhage, left eye)
  • E11.3513 (Type 2 diabetes with proliferative diabetic retinopathy with macular edema, bilateral)
• Place of Service: 11 (Office) or 22 (Hospital outpatient)
• Note: If extensive hemorrhage removal needed → use 67036 instead

Important Distinction:

• 67015: Limited aspiration, needle-based, minimal vitreous removal
• 67036: Mechanical vitrectomy with cutter, extensive removal
• Document amount and method of removal to support code selection

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Example 4: Subretinal Fluid Drainage During Scleral Buckle

Scenario: Patient with rhegmatogenous retinal detachment undergoes scleral buckle placement with external subretinal fluid drainage via pars plana approach.

Coding:

• CPT:
  • 67107-RT (Repair of retinal detachment, scleral buckle with implant)
  • 67015-RT-51 (Subretinal fluid drainage, multiple procedure)
• Diagnosis:
  • H33.001 (Unspecified retinal detachment with retinal break, right eye)
• Place of Service: 22 (Hospital outpatient) or 24 (ASC)
• Modifiers:
  • -51 on 67015: Multiple procedures (secondary procedure paid at reduced rate)
• Payment: 67107 at 100%, 67015 at ~50%

Payer Note: Some payers consider 67015 bundled with 67107. May need modifier 59 and supporting documentation.

---

Example 5: Converted to Full Vitrectomy

Scenario: Patient with suspected endophthalmitis. Procedure started as vitreous tap, but severe vitreous debris and membranes required conversion to full pars plana vitrectomy.

Coding:

• CPT: 67036-RT (Partial pars plana vitrectomy) - NOT 67015
• Diagnosis: H44.001 (Endophthalmitis, right eye)
• Place of Service: 22 or 24

Rationale:

• When simple tap converts to full vitrectomy, bill only the more extensive procedure
• 67036 includes any initial tapping/aspiration
• Do NOT bill both 67015 and 67036
• Document conversion and reason in operative report

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Example 6: Repeat Tap for Persistent Endophthalmitis (Within Global Period)

Scenario: Patient had vitreous tap (67015) 5 days ago for endophthalmitis. Despite intravitreal antibiotics, worsening infection requires repeat tap and culture.

Coding:

• CPT: 67015-RT-78 (Return to OR for related complication)
• Diagnosis:
  • H44.001 (Endophthalmitis, right eye)
  • (May add organism code if identified)
• Place of Service: 22 or 24
• Modifier -78: Indicates return to OR within global period for complication
• Payment: Professional fee paid, but may be reduced
• Does NOT start new global period (continues original 10 days)

---

Example 7: Vitreous Biopsy for Suspected Lymphoma

Scenario: 65-year-old with chronic uveitis unresponsive to treatment. Suspected intraocular lymphoma. Vitreous tap performed for cytology and flow cytometry.

Coding:

• CPT: 67015-LT
• Diagnosis:
  • H30.92 (Unspecified chorioretinal inflammation, left eye)
  • C85.90 (Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites) - if suspected
  • OR: Use “R” codes if truly diagnostic: R93.89 (Other abnormal findings on diagnostic imaging)
• Place of Service: 22 (Hospital outpatient preferred for pathology access)

Documentation Must Include:

• Samples sent to pathology (not just microbiology)
• Tests ordered: Cytology, immunohistochemistry, flow cytometry
• Clinical suspicion for malignancy

---

Example 8: Same-Day E/M with Procedure

Scenario: Patient presents to office with sudden vision loss and pain. Comprehensive examination performed leading to diagnosis of endophthalmitis. Decision made to perform urgent vitreous tap in office. Significant E/M service provided beyond typical pre-operative assessment.

Coding:

• CPT:
  • 99214-25 (Office visit, established patient, level 4, significant separate service)
  • 67015-RT (Vitreous tap)
• Diagnosis: H44.001 (Endophthalmitis)
• Place of Service: 11 (Office)
• Modifier -25: Indicates significant, separately identifiable E/M service

Documentation Requirements:

• E/M must be above and beyond standard pre-operative assessment
• Separate note for E/M documenting:
  • History of present illness
  • Review of systems
  • Comprehensive exam
  • Medical decision-making
  • Plan formulated
• Clear that E/M led to decision for procedure
• Operative report separate from E/M note

---

Example 9: Incomplete Procedure Due to Technical Difficulty

Scenario: Attempted vitreous tap in patient with severe vitreous hemorrhage. Unable to obtain adequate sample despite multiple attempts due to viscous blood clot. Procedure terminated, plan for full vitrectomy next day.

Coding:

• CPT: 67015-RT-52 (Reduced services)
• Diagnosis:
  • H43.11 (Vitreous hemorrhage, right eye)
  • E11.351- (Diabetic retinopathy, if applicable)
• Place of Service: 22 or 24
• Modifier -52: Reduced services
• Charge: Reduce by 50% or more

Documentation:

• “Multiple attempts to aspirate vitreous unsuccessful due to dense hemorrhage”
• “Unable to obtain diagnostic sample”
• “Plan for pars plana vitrectomy tomorrow”
• Clearly state procedure incomplete

Follow-up Vitrectomy (Next Day):

• CPT: 67036-RT-58 (Staged procedure)
• Modifier -58: Indicates planned, staged procedure
• Starts new 10-day global period

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Example 10: Choroidal Fluid Drainage for Choroidal Detachment

Scenario: Patient develops choroidal detachment following trabeculectomy. Suprachoroidal fluid drained via posterior sclerotomy.

Coding:

• CPT: 67015-RT
• Diagnosis:
  • H31.411 (Hemorrhagic choroidal detachment, right eye)
  • H59.49 (Inflammation following other ophthalmic procedure) - if postoperative
• Place of Service: 22 (Hospital outpatient)

Note: 67015 includes drainage of:

• Vitreous
• Subretinal fluid
• Suprachoroidal/choroidal fluid All via pars plana approach - same code

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Reimbursement Information

Medicare Payment (2025 National Average)

Non-Facility (Office-Based Surgery):

• Professional + Technical: ~$1,153.03
• Patient responsibility (20% coinsurance + deductible): ~$230.61
• Medicare pays (80%): ~$922.42

Facility (Hospital Outpatient/ASC):

• Professional component only: ~$206.65
• Facility fee (separate APC): ~$437.10
• Total: ~$643.75
• Patient responsibility: ~$128.75

Bilateral Procedure (Modifier 50):

• Payment: 150% of unilateral
• Office-based: ~$1,729.55
• Facility: ~$965.63

Geographic Variation (2025 Examples)

Non-Facility Payments:

• Manhattan, NY: ~$1,420.00
• San Francisco, CA: ~$1,305.00
• Miami, FL: ~$1,125.00
• Houston, TX: ~$1,085.00
• Rural Alabama: ~$975.00

Variation Due To:

• Work GPCI (physician work geographic adjustment)
• Practice Expense GPCI (overhead costs by locality)
• Malpractice GPCI (malpractice insurance costs)

Commercial Insurance Reimbursement

Typical Ranges:

• PPO Plans: $800-$1,800 (office-based)
• HMO Plans: $600-$1,200
• Medicare Advantage: ~110-120% of Medicare rates
• Medicaid: ~50-80% of Medicare rates (varies by state)

High-Reimbursement Payers:

• Out-of-network: Up to $2,000-$2,500
• Workers’ compensation: ~150-200% of Medicare
• Auto insurance (PIP): Varies widely by state

Global Period Reimbursement

10-Day Global Period Includes:

• Day of surgery
• All post-op visits through day 10
• Normal post-operative care
• Management of complications within global period

Not Included (Bill Separately):

• Complications requiring return to OR (modifier 78)
• Staged procedures (modifier 58)
• Unrelated procedures (modifier 79)
• Unrelated E/M services (modifier 24)

Denial Prevention Strategies

Common Denial Reasons:

1. Lack of Medical Necessity

   • Solution: Document clear indication, failed conservative management
   • Include visual acuity, exam findings, imaging results

2. Incorrect Coding

   • Solution: Use 67036 for full vitrectomy, not 67015
   • Review operative report to ensure procedure matches code

3. Missing/Incorrect Modifiers

   • Solution: Use laterality modifiers (RT/LT)
   • Use modifier 50 for bilateral procedures
   • Use modifier 59 when unbundling necessary

4. Bundling with Other Procedures

   • Solution: Use modifier 59/XU when appropriate
   • Document separate nature of procedures
   • Check CCI edits before billing

5. Inadequate Documentation

   • Solution: Detailed operative report with all elements
   • Clear indication, findings, amount aspirated, complications

6. Global Period Issues

   • Solution: Use appropriate modifiers (78, 58, 79, 24)
   • Clearly document relationship to original procedure

7. Billing More Extensive Code When Simple Tap Performed

   • Solution: Review operative report carefully
   • If simple needle aspiration → 67015
   • If mechanical vitrectomy performed → 67036

Safety and Complications

Intra-Operative Complications

Document and Code Appropriately:

• Lens touch/injury:

  • ICD-10: H59.09- (Other disorders of eye following cataract surgery)
  • May require cataract extraction

• Retinal perforation/tear:

  • ICD-10: S05.2XXA (Ocular laceration without prolapse)
  • May require immediate repair

• Choroidal hemorrhage:

  • ICD-10: H31.2- (Hereditary choroidal dystrophy) or H31.3- (Choroidal hemorrhage)
  • May require drainage or observation

• Hypotony (low IOP):

  • ICD-10: H44.40 (Unspecified hypotony of eye)
  • Monitor closely post-operatively

Post-Operative Complications (Within Global Period)

Included in 67015 Payment:

• Persistent inflammation (expected)
• Mild IOP elevation (managed medically)
• Conjunctival injection
• Mild discomfort

May Require Return to OR (Modifier 78):

• Persistent/recurrent infection:

  • May need repeat tap or full vitrectomy
  • Code: 67015-78 or 67036-78

• Retinal detachment:

  • Code: 67107/67108 with modifier 78
  • ICD-10: H33.0-

• Vitreous hemorrhage:

  • If requires vitrectomy: 67036-78
  • ICD-10: H43.1-

Adverse Events (Code Separately)

• Endophthalmitis (if procedure causes it - rare):

  • ICD-10: H44.001-003
  • T81.4XXA (Infection following procedure)

• Sympathetic ophthalmia (very rare):

  • ICD-10: H44.13-

Contraindications (Document if Present)

Absolute Contraindications:

• Active external eye infection (conjunctivitis, keratitis)
• ICD-10: H10.-, H16.-
• Must treat first, then perform tap

Relative Contraindications:

• Anticoagulation (increased bleeding risk)
• Severe media opacity preventing safe access
• Uncooperative patient without general anesthesia

Quality Measures

MIPS (Merit-Based Incentive Payment System)

Applicable Quality Measures:

• Measure #191: Cataracts - Complications within 30 Days
  • If 67015 performed post-cataract surgery for endophthalmitis
  • Reported as complication
• Measure #141: Primary Open-Angle Glaucoma - Reduction of IOP
  • Not directly applicable to 67015

Surgical Quality Metrics

Track These for Quality Improvement:

• Culture positivity rate (diagnostic yield)
• Time from presentation to tap (for endophthalmitis)
• Successful sample acquisition rate
• Complication rates:
  • Retinal detachment post-procedure
  • Persistent hypotony
  • Need for subsequent vitrectomy

Hospital Quality Reporting

If Performed in Hospital Setting:

• Surgical site infection rates
• Unplanned return to OR within 30 days
• Hospital-acquired conditions (HAC)
• Patient safety indicators (PSI)

Related CPT Codes

Alternative Vitreous Procedures

• 67005: Removal of vitreous, anterior approach (open sky technique or limbal incision)

  • Different surgical approach
  • For anterior segment surgery

• 67010: Removal of vitreous, anterior approach (partial vitrectomy), endo-ocular

  • Anterior approach vitrectomy
  • For lens/anterior segment complications

• 67025: Injection of vitreous substitute, pars plana or limbal approach

  • For gas or silicone oil injection
  • Not for aspiration

• 67028: Intravitreal injection of pharmacologic agent

  • For medication injection (anti-VEGF, antibiotics, steroids)
  • Commonly performed with 67015

• 67030: Discission of vitreous strands (without removal), pars plana approach

  • For severing vitreous adhesions
  • No removal of vitreous

Full Vitrectomy Procedures

• 67036: Vitrectomy, mechanical, pars plana approach (partial)

  • Most common step-up from 67015
  • Mechanical removal with vitrectomy machine
  • Higher RVU (9.52 work RVU vs 6.19 for 67015)

• 67039: Vitrectomy with focal endolaser photocoagulation

• 67040: Vitrectomy with endolaser panretinal photocoagulation

• 67041: Vitrectomy with removal of preretinal cellular membrane

• 67042: Vitrectomy with removal of internal limiting membrane

• 67043: Vitrectomy with removal of subretinal membrane

Retinal Detachment Repair (Often With 67015)

• 67107: Repair of retinal detachment, scleral buckle with implant
• 67108: Repair of retinal detachment, with vitrectomy
• 67110: Repair of retinal detachment, pneumatic retinopexy
• 67113: Repair of complex retinal detachment

Diagnostic Procedures (Pre-Operative)

• 92235: Fluorescein angiography
• 92133-92134: Optical coherence tomography (OCT)
• 76514: Ophthalmic ultrasound, B-scan

Laboratory/Pathology

• 87040: Blood culture
• 87070: Culture, bacterial (vitreous specimen)
• 87075: Culture, bacterial, anaerobic
• 87077: Aerobic isolate identification
• 87086: Culture, bacterial, quantitative colony count
• 87103: Culture, fungi (mold or yeast)
• 87205: Smear, primary source with interpretation (Gram stain)
• 88172: Cytopathology, evaluation of fine needle aspirate (vitreous)

Clinical Pearls for Coders

1. 67015 vs 67036 - Critical Distinction:

   • 67015: Needle aspiration, manual, limited vitreous removal
   • 67036: Mechanical vitrectomy machine, extensive removal
   • Review operative report for equipment used
   • If vitrectomy machine mentioned → use 67036, not 67015

2. Bilateral procedures - Use modifier 50:

   • NOT -RT and -LT separately
   • Bill once with -50
   • Payment: 150% of unilateral fee

3. Endophthalmitis is #1 indication:

   • Always emergent/urgent
   • Usually no prior authorization needed
   • Document timing (postoperative vs endogenous)
   • POA indicator critical for postoperative cases

4. Intravitreal injection commonly follows:

   • Bill 67028 with modifier 59 or XS
   • Document as separate procedure
   • Antibiotics given AFTER culture obtained

5. Global period is 10 days:

   • All normal post-op visits included
   • Complications requiring re-operation: modifier 78
   • Planned staged procedures: modifier 58
   • Unrelated services: modifier 79 or 24

6. Assistant surgeon generally not paid:

   • CMS indicator “1” (payment restriction)
   • Do not routinely bill modifier 80
   • Rare exceptions with detailed documentation

7. Watch for upcoding:

   • If simple needle tap → 67015
   • Don’t use 67036 unless true mechanical vitrectomy
   • Review operative time (67015 typically 15-30 minutes total)

8. Multiple taps same session = one code:

   • Don’t bill 67015 × 2
   • Multiple samples included in single code
   • Document all samples obtained

9. Conversion to full vitrectomy:

   • Bill only 67036 (more extensive)
   • Do NOT bill both 67015 and 67036
   • Document reason for conversion

10. Office-based vs facility coding:

    • Office: Bill global code (higher RVU)
    • Hospital: Professional component only
    • Check place of service code (11 vs 22 vs 24)

11. Documentation must support code:

    • Pars plana approach (not anterior)
    • Amount aspirated
    • Appearance of aspirate
    • Where samples sent
    • Any difficulties

12. Culture results affect diagnosis coding:

    • If organism identified, add B95-B97 codes
    • Update claim if organism identified after initial billing
    • Use specific endophthalmitis codes when organism known

Documentation Template

Sample Operative Report for 67015

PREOPERATIVE DIAGNOSIS: Endophthalmitis, right eye

POSTOPERATIVE DIAGNOSIS: Same

PROCEDURE: Vitreous tap and culture, pars plana approach, right eye

SURGEON: [Name]

ANESTHESIA: Monitored anesthesia care with local anesthesia

INDICATIONS: 
[Age]-year-old [gender] presents [X] days status post [procedure/trauma] with decreased vision, pain, and hypopyon in the right eye consistent with acute endophthalmitis. Vitreous tap indicated for culture and organism identification to guide antibiotic therapy.

DESCRIPTION OF PROCEDURE:
Informed consent was obtained. The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care was administered. The right eye was prepped and draped in sterile fashion using 5% povidone-iodine solution. A lid speculum was placed.

Retrobulbar block was administered with 3mL of 2% lidocaine. The conjunctiva and sclera were inspected. A site 3.5mm posterior to the limbus in the inferotemporal quadrant was selected for pars plana sclerotomy.

Using a 23-gauge needle attached to a tuberculin syringe, the needle was passed obliquely through the pars plana into the vitreous cavity. Gentle aspiration was performed, obtaining approximately 0.3mL of turbid, purulent-appearing vitreous material. 

The undiluted vitreous sample was immediately inoculated into:
- Blood culture bottles (aerobic and anaerobic)
- Chocolate agar plate
- Fungal culture media
- Gram stain slide

The needle was withdrawn. The sclerotomy site was inspected and noted to be self-sealing with no leakage. The conjunctiva was repositioned. Bacitracin ointment was applied. The lid speculum was removed.

Intraocular pressure was checked by palpation and found to be normal. The patient tolerated the procedure well without immediate complications.

FINDINGS:
- Approximately 0.3mL of purulent vitreous aspirated
- No complications encountered
- Samples sent for aerobic, anaerobic, and fungal cultures with Gram stain

PLAN:
- Await culture results
- Continue current antibiotic regimen
- Close follow-up in 24 hours
- Patient instructed to return immediately for worsening symptoms

_______________
[Surgeon Signature]
[Date/Time]

References for Further Study

• CPT® 2025 Professional Edition - American Medical Association
• Medicare Physician Fee Schedule (MPFS) 2025
• National Correct Coding Initiative (NCCI) Policy Manual
• CMS MS-DRG Definitions Manual (FY2025)
• American Academy of Ophthalmology Coding Guidelines
• Endophthalmitis Vitrectomy Study (EVS) Group Protocols
• Retina Coding ICD-10-CM and CPT® - American Society of Retina Specialists

Update History

• 2025: No significant changes to code definition
• Work RVU: Remains 6.19 (unchanged from 2024)
• Global Period: Remains 10 days
• Valid through: At least 2025