67036

CPT Code 67036: Documentation & Billing Guide

🏥 67036: Vitrectomy, mechanical, pars plana approach

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⚡ Quick Reference

Metric	Value	Notes
Common Mod	-50	(Primary modifier for this service)
Global	090	(Major Surgery - requires -57/-79)
wRVU	13.06
Assist	Yes	(Yes (Modifier -80, -81, or -AS may be used if medically necessary))

🚧 Bundling & NCCI Edits

(What is INCLUDED in this code?)

• Includes: 67015 (Aspiration of vitreous), 67025 (Injection of vitreous substitute), 67031 (Laser of vitreous strands), and 67121 (Removal of implanted material) are generally bundled when performed in the same eye.
• Mutually Exclusive: Often bundled with more complex retinal repair codes like 67108 or 67113; if a more comprehensive repair is performed, the complex code is billed instead of 67036.

📝 MCW/Payer Specifics

• Medical Necessity: Documentation must support ophthalmology complexity.
• Mod -22: If applicable, look for >50% extra time/effort.
• Modifier Info: Ensure bilateral documentation (e.g., ‘both sides’ or ‘left and right’) is clear.
• Category: This is a OPHTHALMOLOGY specific procedure.

CPT code 67036 refers to a Pars Plana Vitrectomy (PPV). This is a surgical procedure where the vitreous humor (the clear gel filling the eye) is mechanically removed to treat various retinal and vitreous conditions.This code is used for the primary mechanical removal of vitreous fluid via the pars plana to address conditions like vitreous hemorrhage, tractional retinal detachment, or to clear the field for other posterior segment work.

Comparison with Related Codes:

If additional services are performed during the vitrectomy, one of the following codes may be more appropriate:

• 67039: Vitrectomy with focal endolaser photocoagulation.

• 67040: Vitrectomy with endolaser panretinal photocoagulation.

• 67041: Vitrectomy with removal of preretinal cellular membrane (e.g., macular pucker/epiretinal membrane).

🔗 Related Op Reports

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From NotebookLM:

CPT 67036: Pars Plana Vitrectomy (PPV)

Code Definition

• 67036: vitrectomy, mechanical, pars plana approach.
  • Use Context: This is the “base” code for a vitrectomy. It describes the removal of the vitreous gel. It is often used for clearing vitreous hemorrhage, opacities, or simple detachments where no membrane peeling or scleral buckling is performed.

Global Period & RVU

• Global Period: 090 Days (Major Surgery).
• Work RVU (2025): ~12.13.
• Bilateral Status: Indicator “1” (150% payment for bilateral with Modifier 50).

Critical Bundling Rules (NCCI)

• Lensectomy (66850):
  • Rule: Removal of lens material (66850) is generally bundled into 67036.
  • Exception: You may only unbundle 66850 if the lens is removed and an IOL is NOT inserted (patient is left aphakic).
• Retinal Detachment Repairs:
  • Do not bill 67036 with 67108 (RD repair with vitrectomy) or 67113 (Complex RD repair) on the same eye. The vitrectomy is inherent to those codes.
• Membrane Peeling:
  • Do not bill 67036 with 67041 (ERM peel) or 67042 (ILM peel). These higher-level codes include the vitrectomy.
• Injections:
  • Air, gas, or silicone oil tamponade is included.
  • Intravitreal injections (67028) performed at the time of surgery are generally bundled.

Code Hierarchy (Do Not Stack)

Select only one from this family per eye:

1. 67036: PPV (Base).
2. 67041: PPV + Preretinal Membrane Peel (Macular Pucker).
3. 67042: PPV + ILM Peel (Macular Hole/Edema).
4. 67108: PPV + Scleral Buckle/Laser/Gas (Rhegmatogenous RD).
5. 67113: PPV + Membrane Peel + Complex factors (PVR/TRD).

Specific Exclusions (Gene Therapy)

• Luxturna/Gene Therapy: Do not use 67036 for the administration of subretinal gene therapy (e.g., Luxturna).
  • Use Code: C9770 (Vitrectomy with subretinal injection of pharmacologic/biologic agent).
• Subretinal Injection: See also Category III code 0810T for subretinal injection with vitrectomy.

Coverage Indications (LCD)

Medicare generally covers 67036 for:

• vitreous hemorrhage or opacities.
• Retinal detachment secondary to vitreous strands.
• Proliferative retinopathy.
• Vitreous loss incident to cataract surgery.