Crystal's MCW Coder Hub🩺 CPT 67113 — Repair of Complex Retinal Detachment with Vitrectomy
Code Description
CPT 67113 describes the surgical repair of a complex retinal detachment using pars plana vitrectomy (PPV) as the primary operative approach, encompassing a defined set of qualifying pathologic conditions that elevate the procedure beyond the scope of a standard retinal detachment repair (CPT 67108). This is the highest-complexity, highest-weighted retinal detachment repair code in the CPT system and reflects the substantially greater operative time, technical difficulty, intraoperative risk, and unpredictability inherent in managing retinal detachments complicated by advanced proliferative disease, traction, or structural anomalies.
The full CPT descriptor reads: Repair of complex retinal detachment (e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinoschisis, retinal or choroidal coloboma, etc.) with vitrectomy and, if performed, vitreous substitutes (e.g., air, gas, or silicone oil), cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.
The phrase “e.g.” (exempli gratia — meaning “for example”) in the CPT descriptor is critically important. It establishes that the listed conditions are illustrative examples, not an exhaustive or closed list. CPT 67113 applies whenever the detachment is of sufficient complexity to require the techniques and operative resources that exceed those of a standard vitrectomy-based repair (CPT 67108), whether or not the specific pathology matches one of the named examples exactly. The operative report must clearly document the nature of the complexity, the specific pathological features encountered, and the techniques employed to address them.
The distinguishing features of CPT 67113 over CPT 67108 are both pathologic and technical. Pathologically, CPT 67113 requires the presence of a qualifying complex condition. Technically, CPT 67113 procedures typically involve advanced maneuvers such as membrane peeling and segmentation, relaxing retinotomies or retinectomies, use of perfluorocarbon liquid (PFCL) for retinal flattening, extended surgical time, and long-acting tamponade with silicone oil rather than short-acting gas.
Qualifying Complex Conditions
CPT 67113 is appropriate when the retinal detachment is associated with one or more of the following qualifying conditions. Each is described in detail below.
Proliferative Vitreoretinopathy (PVR), Stage C-1 or Greater
Proliferative vitreoretinopathy is the most common cause of failed retinal detachment surgery and is the paradigmatic indication for CPT 67113. PVR occurs when retinal pigment epithelial (RPE) cells and glial cells migrate through retinal breaks, proliferate on the vitreous surface and inner and outer retinal surfaces, and form contractile fibrocellular membranes. These membranes distort, fold, and ultimately re-detach the retina by traction.
The Retina Society Classification of PVR (widely used despite being based on older terminology) stages PVR as:
- Grade A — vitreous haze, pigment clumps
- Grade B — wrinkling of the inner retinal surface, rolled edge of break, retinal stiffness
- Grade C — full-thickness retinal folds, fixed star folds; subclassified by location (anterior vs. posterior) and extent (number of clock hours); Stage C-1 implies one quadrant (3 clock hours) of fixed folds
CPT 67113 is applicable for PVR Stage C-1 or greater (C-2, C-3, and all anterior PVR). Grade B PVR does not qualify. Anterior PVR — in which contractile membranes form anterior to the equator, causing circumferential retinal shortening and anterior displacement of the retina into the ciliary body zone — is among the most challenging forms of PVR to repair and may require retinectomy.
Operative techniques required for PVR include:
- Membrane peeling — delicate delamination of epiretinal and subretinal membranes using end-gripping forceps, membrane picks, and micro-scissors
- Segmentation — cutting membranes into segments to relieve traction without full membrane removal
- Delamination — separation of fibrovascular or fibrocellular membranes from the retinal surface
- Relaxing retinotomy — a radial incision in the retina to relieve tangential traction
- Relaxing retinectomy — excision of a portion of the retina when traction is too severe to relieve by membrane peeling alone; the most aggressive technique, reserved for cases where the retina cannot be flattened by other means
- PFCL injection — perfluorocarbon liquids are heavy liquids injected into the vitreous cavity to hydraulically flatten the posterior retina while anterior dissection continues
- Silicone oil tamponade — long-acting tamponade (1000 cs or 5000 cs silicone oil) is almost universally employed for PVR repair due to the high risk of re-proliferation and re-detachment with shorter-acting gas tamponade
Diabetic Traction Retinal Detachment (TRD)
Diabetic traction retinal detachment occurs as a late complication of proliferative diabetic retinopathy (PDR). Uncontrolled neovascularization leads to formation of fibrovascular proliferative membranes in the vitreous and on the retinal surface. As these membranes contract, they exert tangential and anteroposterior traction forces on the retina, eventually causing separation of the retina from the RPE. When the traction detachment involves or threatens the macula, surgical repair is indicated.
CPT 67113 is explicitly named in the descriptor for diabetic traction retinal detachment. This differs from CPT 67108, which may be used for simpler tractional detachments without the extensive fibrovascular membrane burden typical of severe PDR. The operative complexity in diabetic TRD arises from:
- Dense, vascularized fibrovascular membranes that must be carefully dissected, segmented, and delaminated from the retinal surface; aggressive membrane removal risks intraoperative hemorrhage and iatrogenic retinal tears
- Intraoperative bleeding from neovascular tissue, which may require endodiathermy and careful hemostatic technique
- Combined tractional-rhegmatogenous detachments where retinal breaks have developed within areas of traction, requiring both membrane dissection and break treatment
- Posterior hyaloid adherence — the posterior vitreous cortex may be densely adherent to the fibrovascular complex, requiring meticulous dissection
- Peripheral fibrovascular proliferation requiring careful shaving of the vitreous base
- Pan-endolaser photocoagulation — typically performed at the same session to ablate ischemic peripheral retina and reduce the stimulus for further neovascularization
The presence of an active traction retinal detachment from diabetic proliferative retinopathy documented in the operative report supports use of CPT 67113 regardless of whether other advanced techniques (retinotomy, PFCL) were required.
Retinopathy of Prematurity (ROP)
Retinopathy of prematurity is a vasoproliferative retinal disease affecting premature infants with incompletely vascularized retinas at birth. In severe cases (Stage 4 and Stage 5 ROP), partial or total retinal detachment occurs due to fibrovascular proliferation at the ridge between vascularized and avascular retina. Surgical repair of Stage 4 and 5 ROP detachments falls under CPT 67113.
Operative management of ROP detachments is among the most technically demanding vitreoretinal procedures, performed on eyes with:
- Extremely small axial length (microphthalmos relative to adult standards)
- Rigid, thickened posterior hyaloid and lens capsule
- Funnel-shaped retinal detachments in Stage 5
- Limited surgical working space
- Requirement for ultra-small gauge (27-gauge) instrumentation
- Concurrent lens removal (lensectomy) often required for access to the posterior segment in Stage 5
Retinoschisis with Retinal Detachment
Retinoschisis — splitting of the retinal layers — can, in its more advanced forms (particularly degenerative retinoschisis and X-linked juvenile retinoschisis), be associated with outer layer breaks and progression to true retinal detachment. When retinoschisis is complicated by retinal detachment requiring vitrectomy, CPT 67113 applies. The added complexity arises from the schitic retinal tissue, which is fragile and technically difficult to manipulate, and the challenge of identifying and treating outer layer breaks in a split retina.
Retinal or Choroidal Coloboma with Retinal Detachment
Retinal or choroidal colobomata are congenital structural defects resulting from incomplete closure of the embryonic fissure. These defects create anatomically abnormal zones of thin or absent retinal and choroidal tissue. When retinal detachments develop in association with colobomata (typically through breaks at the coloboma margin), the surgical repair is complex due to the abnormal anatomy, absent RPE in the coloboma zone, and risk of recurrent detachment through persistent coloboma-associated breaks.
Other Qualifying Complex Conditions (the “Etc.” Category)
The CPT descriptor includes “etc.” at the end of its example list, explicitly acknowledging additional qualifying complex conditions. These may include:
- Giant retinal tear (GRT) with PVR or complex pathology — while GRTs may initially be repaired with CPT 67108, those complicated by PVR, folded retina, or requiring PFCL and retinectomy qualify for 67113
- Traumatic retinal detachment with severe PVR or intraocular foreign body-related complications
- Choroidal detachment with hypotony and retinal detachment — repair requiring specialized technique to re-expand the choroid and treat the retinal detachment simultaneously
- Silicone oil-related complications requiring complex revision — including emulsified oil, band keratopathy from oil migration, and glaucoma requiring oil removal with concurrent retinal manipulation
- Subretinal membrane formation (subretinal PVR, subretinal bands) requiring posterior retinotomy for subretinal membrane removal
- Proliferative sickle retinopathy with traction detachment in medically complex patients
Operative Overview
Pre-Operative Planning
Complex retinal detachment repair requires detailed pre-operative assessment including:
- Wide-field fundus photography and fundus drawing to document detachment extent, PVR location and stage, retinal breaks, and membrane configuration
- Optical coherence tomography (OCT) of the macula to assess macular involvement, degree of subretinal fluid, and presence of epiretinal membrane
- B-scan ultrasonography to assess posterior segment in cases of media opacity (vitreous hemorrhage, cataract)
- Review of prior operative reports in re-detachment cases to understand previous surgical anatomy and remaining scleral buckle if present
Intraoperative Approach
Small-Gauge Vitrectomy System Setup (23-gauge, 25-gauge, or 27-gauge) Three-port pars plana sclerotomies are created for the infusion cannula, light source, and vitreous cutter. In complex cases, a chandelier endoilluminator may be used to free one hand for bimanual dissection.
Core and Peripheral Vitrectomy Complete core vitrectomy is performed followed by meticulous peripheral vitreous base shaving to the ora serrata, which is essential in PVR and diabetic TRD to relieve anteroposterior traction.
Posterior Hyaloid Separation and Removal The posterior vitreous cortex is separated from the retinal surface using suction or pick engagement at the optic nerve head and peeled anteriorly. In PVR, the posterior hyaloid is often fused with the epiretinal membrane complex.
Membrane Peeling, Segmentation, and Delamination In PVR and diabetic TRD, this is the most time-consuming and technically demanding portion of the procedure. Membranes are engaged with end-gripping forceps and peeled tangentially from the retinal surface. Scissors are used to segment tightly adherent membranes. In diabetic TRD, the fibrovascular membranes are delaminated from the retinal surface using bimanual technique with scissors in one hand and the light pipe or forceps in the other (bimanual vitreous surgery).
Retinotomy or Retinectomy (if required) In severe PVR with a foreshortened retina that cannot be flattened despite complete membrane removal, a relaxing retinotomy (radial cut) or retinectomy (removal of a peripheral retinal crescent) is performed to allow the retina to unfurl and flatten.
PFCL Injection Perfluorocarbon liquid (e.g., perfluoro-n-octane) is injected over the optic nerve to hydraulically flatten the posterior retina while anterior membrane dissection continues under the PFCL bubble. PFCL is heavier than water and sinks posteriorly, displacing subretinal fluid through anterior breaks.
Endolaser Photocoagulation Confluent, two to three burn-width laser photocoagulation is applied around all retinal breaks, tears, and retinotomy/retinectomy margins. In diabetic TRD, pan-endolaser photocoagulation to the peripheral avascular retina is performed.
Cryotherapy Cryotherapy is applied transsclerally to peripheral breaks inaccessible to endolaser, particularly in anterior PVR or for breaks at or anterior to the vitreous base.
Fluid-PFCL Exchange and PFCL-Gas/Oil Exchange PFCL is exchanged for the final tamponade agent in a two-step process. First, fluid-gas exchange removes residual PFCL and subretinal fluid while maintaining retinal apposition. Then, the gas or silicone oil is introduced.
Tamponade Selection
- Silicone oil (1000 cs or 5000 cs) — preferred for PVR, diabetic TRD, inferior detachments, patients unable to position post-operatively, pediatric patients, and cases with high re-detachment risk; oil provides prolonged tamponade but requires a second surgical procedure for removal (CPT 67121) after retinal stability is confirmed (typically 3-6 months)
- Long-acting gas (C3F8 — perfluoropropane) — used in selected cases where patient compliance with prone positioning is reliable and re-proliferation risk is lower; C3F8 remains in the eye for 6-8 weeks
Scleral Buckle An encircling scleral buckle (typically a 240 band) is often added in complex cases to support the vitreous base, relieve anteroposterior traction, and prevent anterior PVR re-detachment. The buckle is bundled into CPT 67113 when performed at the same operative session.
Includes (Bundled — Do Not Report Separately)
All of the following, when performed at the same operative session as the vitrectomy for complex retinal detachment repair, are explicitly bundled into CPT 67113:
- Pars plana vitrectomy (PPV) — any gauge (20g, 23g, 25g, 27g)
- Membrane peeling, segmentation, and delamination — epiretinal, subretinal, or fibrovascular membranes
- Relaxing retinotomy and/or retinectomy — including peripheral retinal excision
- Perfluorocarbon liquid (PFCL) injection and removal
- Fluid-air exchange (FAX)
- Endolaser photocoagulation — focal, sectoral, panretinal, or at retinotomy/retinectomy margins
- Cryotherapy — transscleral for peripheral breaks
- Silicone oil injection (tamponade) — 1000 cs or 5000 cs
- Gas tamponade — SF6, C2F6, C3F8 — expansile or non-expansile
- Air tamponade
- Drainage of subretinal fluid — internal (PFCL-assisted) or external (transscleral)
- Scleral buckling — segmental or encircling (240 band or equivalent)
- Lens removal (lensectomy) — if performed to facilitate access or remove a cataractous lens at the same session
- Endodiathermy — for hemostasis of retinal vessels during membrane peeling
- Chandelier light placement for bimanual vitreous surgery
- Vitreous base shaving — peripheral vitrectomy
- Infusion cannula placement and removal
- Sclerotomy creation and closure
Excludes / Report Separately
-
Silicone oil removal at a separate subsequent operative encounter — CPT 67121 (removal of implanted material from posterior segment, intravitreal); this is a separate surgery typically performed 3-6 months after primary repair and is separately reportable with its own 90-day global period
-
Standard (non-complex) retinal detachment repair with vitrectomy — CPT 67108; when the detachment does not involve a qualifying complex condition, 67108 is the appropriate code; do not upcode to 67113 without clear documentation of a qualifying complex pathology
-
Scleral buckling alone without vitrectomy — CPT 67107; if vitrectomy is NOT performed and scleral buckling alone is the operative approach, use 67107; however, if scleral buckling is performed IN ADDITION to vitrectomy for complex detachment, the buckle is bundled into 67113
-
Pneumatic retinopexy — CPT 67110; in-office gas injection for select uncomplicated detachments; not applicable to complex detachments qualifying for 67113
-
Retinal photocoagulation at a separate operative session — CPT 67210 (focal/scatter), 67228 (panretinal photocoagulation, PPV, one or more sessions); separately reportable if performed at a distinct session outside the global period
-
Intravitreal injection of pharmacologic agent (e.g., anti-VEGF, triamcinolone) at a separate session — CPT 67028; if an intravitreal injection is performed at a completely separate visit, it is separately reportable; if injected at the time of complex retinal detachment repair surgery, it is generally bundled
-
Cataract surgery with IOL implantation at a separate session — CPT 66982 or 66984; if phacoemulsification with IOL is performed as a distinct, medically necessary procedure at a separate operative encounter, it is separately reportable; if lens removal is performed at the SAME session as 67113 to facilitate vitreous access, it is bundled
-
Pars plana vitrectomy for indications other than retinal detachment — CPT 67036 (mechanical vitrectomy, pars plana), 67039, 67040, 67041, 67042, 67043 — for vitreous hemorrhage, macular hole, epiretinal membrane, or other posterior segment conditions without retinal detachment; these are distinct codes for distinct indications
-
Glaucoma procedures performed at the same session for silicone oil-induced or steroid-induced glaucoma — may be separately reportable depending on the specific procedure (trabeculectomy CPT 66170/66172, tube shunt CPT 66180, etc.) and NCCI edit status
-
Intraocular lens repositioning or removal — if an IOL is repositioned or removed as a distinct procedure during the same session, evaluate NCCI edits for bundling with 67113
-
Corneal procedures performed at the same session (e.g., keratoprosthesis, corneal transplant) — separately reportable as these involve a distinct body part (cornea) under distinct CPT codes
Code Tree — Complex and Standard Retinal Detachment Repair
| CPT Code | Description |
|---|---|
| 67101 | Repair of retinal detachment; cryotherapy or diathermy, with or without drainage of subretinal fluid |
| 67105 | Repair of retinal detachment; photocoagulation, one or more sessions |
| 67107 | Repair of retinal detachment; scleral buckling, with or without implant, with or without cryotherapy, photocoagulation, and/or drainage of subretinal fluid |
| 67108 | Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens |
| 67110 | Repair of retinal detachment; by injection of air or other gas (pneumatic retinopexy) |
| 67113 | Repair of complex retinal detachment with vitrectomy and, if performed, vitreous substitutes, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens — this code |
| 67121 | Removal of implanted material from posterior segment; intravitreal (silicone oil removal) |
| 67141 | Prophylaxis of retinal detachment; cryotherapy or diathermy |
| 67145 | Prophylaxis of retinal detachment; photocoagulation |
| 67036 | Vitrectomy, mechanical, pars plana approach |
| 67039 | Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation |
| 67040 | Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation, with or without scleral buckling |
| 67041 | Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (e.g., macular pucker) |
| 67042 | Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (e.g., for repair of macular hole, diabetic macular edema), includes if performed, intraocular tamponade (i.e., air, gas, or silicone oil) |
| 67043 | Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (e.g., choroidal neovascularization) |
| 67228 | Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation |
Key Distinction — 67113 vs. 67108: CPT 67108 is the standard vitrectomy-based retinal detachment repair code for uncomplicated or moderately complex detachments. CPT 67113 is reserved for detachments with specific qualifying complex pathology — PVR Stage C-1 or greater, diabetic TRD, ROP Stage 4/5, retinoschisis with detachment, retinal or choroidal coloboma with detachment, or equivalent complexity. The difference in wRVU (23.68 for 67108 vs. 31.52 for 67113) reflects the substantially greater operative time, technical skill, and intraoperative risk of complex detachment repair. Documentation of the specific complex pathology in the operative report is mandatory to support 67113. A vague reference to “complex detachment” without specific pathology documentation is insufficient.
Key Distinction — 67113 vs. 67036-67043 (Vitrectomy Without Detachment): The vitrectomy codes 67036-67043 describe pars plana vitrectomy for conditions that do NOT involve retinal detachment (vitreous hemorrhage, macular pucker, macular hole, subretinal membrane, etc.). When a patient undergoes vitrectomy for one of these conditions AND an incidental retinal detachment is discovered and repaired at the same session, the appropriate code shifts to 67108 or 67113 depending on complexity. Do not report both a non-detachment vitrectomy code (67036-67043) and a retinal detachment repair code (67108/67113) for the same eye at the same session.
Key Distinction — 67113 and the “Etc.” Qualifier: The CPT descriptor for 67113 uses “e.g.” (for example) and concludes with “etc.” This means the code is NOT limited to the explicitly named conditions. A vitreoretinal surgeon who documents that a retinal detachment required advanced operative techniques equivalent in complexity to PVR C-1 repair — even if the specific pathology is not one of the named examples — may have a defensible basis for using 67113. Documentation of the specific pathologic features, operative complexity, and techniques employed is essential to support this determination on audit.
ICD-10-CM Diagnosis Codes
Retinal Detachment — Primary Diagnoses
| ICD-10-CM | Description |
|---|---|
| H33.001 | Unspecified retinal detachment with retinal break, right eye |
| H31.402 | Unspecified retinal detachment with retinal break, left eye |
| H33.011 | Retinal detachment with single break, right eye |
| H33.012 | Retinal detachment with single break, left eye |
| H33.021 | Retinal detachment with multiple breaks, right eye |
| H33.022 | Retinal detachment with multiple breaks, left eye |
| H33.031 | Retinal detachment with giant retinal tear, right eye |
| H33.032 | Retinal detachment with giant retinal tear, left eye |
| H33.041 | Retinal detachment with retinal dialysis, right eye |
| H33.042 | Retinal detachment with retinal dialysis, left eye |
| H33.051 | Total retinal detachment, right eye |
| H33.052 | Total retinal detachment, left eye |
| H33.41 | Traction detachment of retina, right eye |
| H33.42 | Traction detachment of retina, left eye |
Proliferative Vitreoretinopathy
| ICD-10-CM | Description | HCC |
|---|---|---|
| H35.371 | Proliferative vitreo-retinopathy with retinal detachment, right eye | No direct HCC |
| H35.372 | Proliferative vitreo-retinopathy with retinal detachment, left eye | No direct HCC |
| H35.373 | Proliferative vitreo-retinopathy with retinal detachment, bilateral | No direct HCC |
Diabetic Retinal Detachment
| ICD-10-CM | Description | HCC |
|---|---|---|
| E11.351 | Type 2 DM with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye | HCC 18 |
| E11.352 | Type 2 DM with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye | HCC 18 |
| E11.353 | Type 2 DM with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye | HCC 18 |
| E11.354 | Type 2 DM with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye | HCC 18 |
| E11.355 | Type 2 DM with stable proliferative diabetic retinopathy, right eye | HCC 18 |
| E11.359 | Type 2 DM with proliferative diabetic retinopathy without macular edema, unspecified eye | HCC 18 |
| E10.351 | Type 1 DM with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye | HCC 18 |
| E10.352 | Type 1 DM with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye | HCC 18 |
| E10.353 | Type 1 DM with proliferative diabeti retinopathy with traction retinal detachment not involving the macula, right eye | HCC 18 |
| E10.354 | Type 1 DM with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye | HCC 18 |
| E13.351 | Other specified DM with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye | HCC 18 |
Retinopathy of Prematurity
| ICD-10-CM | Description | HCC |
|---|---|---|
| H35.141 | Retinopathy of prematurity, stage 4, right eye | No HCC |
| H35.142 | Retinopathy of prematurity, stage 4, left eye | No HCC |
| H35.143 | Retinopathy of prematurity, stage 4, bilateral | No HCC |
| H35.151 | Retinopathy of prematurity, stage 5, right eye | No HCC |
| H35.152 | Retinopathy of prematurity, stage 5, left eye | No HCC |
| H35.153 | Retinopathy of prematurity, stage 5, bilateral | No HCC |
Retinoschisis
| ICD-10-CM | Description | HCC |
|---|---|---|
| H33.101 | Retinoschisis, unspecified, right eye | No HCC |
| H33.102 | Retinoschisis, unspecified, left eye | No HCC |
| H33.111 | Cyst of ora serrata, right eye | No HCC |
| H33.121 | Parasitic cyst of retina, right eye | No HCC |
Choroidal and Retinal Coloboma
| ICD-10-CM | Description | HCC |
|---|---|---|
| H31.201 | Choroidal detachment, unspecified, right eye | No HCC |
| H31.202 | Choroidal detachment, unspecified, left eye | No HCC |
| Q14.2 | Congenital malformation of retina (coloboma of retina) | No HCC |
| Q14.3 | Congenital malformation of choroid (coloboma of choroid) | No HCC |
Vision Loss as Secondary Diagnosis
| ICD-10-CM | Description | HCC |
|---|---|---|
| H54.511 | Low vision right eye, category 1, normal vision left eye | HCC 124 |
| H54.512 | Low vision right eye, category 2, normal vision left eye | HCC 124 |
| H54.10 | Blindness, one eye, unspecified eye | HCC 124 |
| H54.40 | Blindness, one eye, low vision other eye | HCC 124 |
| H54.0X33 | Blindness both eyes, category 3 | HCC 124 |
HCC Coding for Diabetic TRD — Critical Documentation Point: When retinal detachment is a direct manifestation of diabetic proliferative retinopathy, the E10-E13 combination codes (E11.351-E11.354 for Type 2, E10.351-E10.354 for Type 1) capture both the underlying diabetes AND the retinal detachment in a single code. These combination codes are preferred over separately coding the diabetes (E11.9) plus the retinal detachment (H33.41), as they provide greater specificity and correctly map to HCC 18 (Diabetes with Chronic Complications) in the CMS-HCC risk adjustment model. HCC 18 carries meaningful RAF weight and reflects the true clinical burden of diabetic eye disease. Always query documentation to confirm the type of diabetes (Type 1 vs. Type 2), the specific type of proliferative change (traction detachment, combined detachment), the laterality, and macular involvement status, as each of these factors determines the exact ICD-10-CM code.
Vision Loss HCC Mapping: When a patient undergoing complex retinal detachment repair has documented low vision or blindness in the operative eye, the vision status codes (H54.x) may be appropriate as secondary diagnoses. These map to HCC 124 (Exudative Macular Degeneration) under CMS-HCC v24 or equivalent vision loss HCCs in v28. Ensuring vision loss is accurately documented and coded when present adds clinical completeness and appropriate RAF contribution for these medically complex patients.
HCC Relevance
| ICD-10-CM | HCC Category | Clinical Significance |
|---|---|---|
| E11.351-E11.354 | HCC 18 — Diabetes with Chronic Complications | High — diabetic TRD with macular involvement |
| E10.351-E10.354 | HCC 18 — Diabetes with Chronic Complications | High — Type 1 diabetic TRD |
| E13.351-E13.354 | HCC 18 — Diabetes with Chronic Complications | High — other specified DM with TRD |
| H54.0-H54.5 | HCC 124 — Vision Loss | Moderate — if blindness or low vision documented |
| H35.371-H35.373 | No direct HCC | PVR itself is not HCC-mapped |
| H33.001-H33.052 | No direct HCC | Retinal detachment codes not HCC-mapped |
HCC Strategy for Complex Retinal Detachment Cases: The most impactful HCC-coding opportunity in the context of CPT 67113 is the accurate capture of diabetic TRD with the appropriate E-code combination code (E11.351-E11.354 or E10.351-E10.354). These codes map to HCC 18 and should be assigned as the principal diagnosis when the retinal detachment is a direct result of diabetic proliferative retinopathy — rather than defaulting to H33.41 (traction detachment of retina) with a separate diabetes code. The combination code is both clinically more accurate and appropriately more specific for risk adjustment.
Additionally, when patients present with reduced visual acuity or blindness in the operative eye pre-operatively (common in longstanding PVR or diabetic TRD), coding the vision loss (H54.x) as a secondary diagnosis ensures HCC 124 is captured. Physicians should document the pre-operative visual acuity and functional vision status explicitly to support this coding.
Secondary diabetes comorbidities — nephropathy (N18.x), neuropathy (E11.40-E11.49), peripheral vascular disease — present in many diabetic TRD patients should also be coded as secondary diagnoses when documented, as they may contribute to additional HCC assignments (HCC 85, HCC 18, HCC 17, etc.) and accurately reflect the patient’s overall disease burden.
wRVU and Reimbursement
| Metric | Value |
|---|---|
| Work RVU (wRVU) | 31.52 |
| Total RVU (facility, national avg) | ~43.00-47.00 |
| Total RVU (non-facility / ASC) | ~58.00-65.00+ |
| Global Period | 90 days |
| Assistant Surgeon Payable | Yes — modifier -80, -82, or -AS |
| Co-Surgeon | Generally not applicable; may apply in ROP surgery in select academic centers |
| Bilateral | Extremely rare; report separately with -RT and -LT if documented |
| Modifier -50 | Not applicable for bilateral eye surgery; use -RT and -LT |
| Teaching Physician | Modifier -GC in academic settings |
| Anesthesia CPT | 00147 — anesthesia for intraocular procedures; not otherwise specified |
| Operative Time | Typically 2-5+ hours for complex cases; significantly longer than standard PPV |
wRVU Context — 67113 vs. 67108: CPT 67113 carries a wRVU of 31.52 compared to 23.68 for CPT 67108 — a difference of approximately 7.84 wRVU per case. At a typical conversion factor (~$70-80 per wRVU), this represents a substantial difference in reimbursement per case. This differential reflects the recognition within the CPT valuation process that complex retinal detachment repair requires materially greater physician work — longer operative time, greater cognitive intensity, higher intraoperative decision-making burden, and substantially greater post-operative complexity management. The clinical justification for 67113 over 67108 must be thoroughly documented; upcoding without documentation of qualifying complex pathology is an audit risk.
Assistant Payable Detail: CPT 67113 is assistant-payable, reflecting the genuine clinical need for an assistant surgeon in many complex retinal detachment cases. Bimanual vitreous surgery for PVR membrane peeling, management of massive intraoperative hemorrhage in diabetic TRD, or chandelier-assisted surgery all benefit from or require an assistant. In teaching environments, a retina fellow or resident functioning as a supervised first assistant adds genuine surgical value. The assistant’s participation and role should be documented in the operative report to support assistant surgeon billing.
Facility vs. Non-Facility Setting: The majority of CPT 67113 cases are performed in an ASC or hospital outpatient department. True inpatient admission is uncommon for isolated complex retinal detachment but may occur in patients with significant systemic comorbidities (uncontrolled diabetes, cardiac disease, prior stroke), bilateral simultaneous ROP surgery in neonatal ICU patients, or post-operative complications requiring monitoring. The non-facility total RVU is substantially higher than the facility RVU because the facility separately bills technical costs (equipment, supplies, staff, anesthesia), and the physician’s non-facility PE RVU reflects these resources when the procedure is performed in an office-based surgical suite.
MS-DRG Assignment
Complex retinal detachment repair is predominantly an outpatient or ASC procedure. Inpatient admission, when it occurs, is driven by systemic comorbidities, bilateral surgery (particularly neonatal ROP), or post-operative complications. When an inpatient claim is generated, the MS-DRG is determined by the principal diagnosis and the ICD-10-PCS procedure codes assigned.
| MS-DRG | Description | Type |
|---|---|---|
| 116 | Intraocular Procedures with CC/MCC | Surgical |
| 117 | Intraocular Procedures without CC/MCC | Surgical |
| 124 | Other Disorders of the Eye with MCC | Medical — if no qualifying surgical ICD-10-PCS code |
| 125 | Other Disorders of the Eye without MCC | Medical |
| 637 | Diabetes with MCC | Medical — if diabetic TRD drives principal Dx without qualifying OR procedure |
| 638 | Diabetes with CC | Medical |
| 639 | Diabetes without CC/MCC | Medical |
MS-DRG Coding Guidance: When a patient is admitted inpatient for complex retinal detachment repair, accurate ICD-10-PCS coding is essential to ensure the claim groups to a surgical DRG (116/117) rather than a medical DRG (124/125 or diabetic DRGs). The ICD-10-PCS procedure code — specifically the vitreous extirpation (08C53ZZ or 08C63ZZ) and retinal repair (08QK3ZZ or 08QL3ZZ) codes — must be present on the UB-04 to trigger the surgical DRG. Surgical DRGs carry substantially higher relative weight and reimbursement than their medical counterparts for the same principal diagnosis.
For diabetic TRD cases, the principal diagnosis of E11.351-E11.354 combined with ICD-10-PCS codes for vitrectomy and retinal repair should group to DRG 116/117 (Intraocular Procedures) rather than the diabetes medical DRGs, since a qualifying intraocular OR procedure is being performed. If the ICD-10-PCS codes are missing or incomplete, the claim may incorrectly group to a medical DRG with significantly lower reimbursement — a frequent inpatient coding error.
MCC and CC Impact: In the inpatient setting, the presence of MCC conditions such as uncontrolled diabetes (E11.649), sepsis, respiratory failure, acute kidney injury, or malnutrition will shift DRG 117 to DRG 116 with meaningfully higher relative weight. Accurate and complete secondary diagnosis coding — including all documented comorbidities and complications — is essential for appropriate MS-DRG assignment and reimbursement.
ICD-10-PCS Equivalents (Inpatient Facility Coding)
For inpatient cases, multiple ICD-10-PCS codes are required to capture all components of a complex retinal detachment repair. Each distinct root operation on each distinct body part requires a separate code.
| ICD-10-PCS Code | Description | Clinical Application |
|---|---|---|
| 08C53ZZ | Extirpation of Matter from Right Vitreous, Percutaneous Approach | Core vitrectomy, right eye |
| 08C63ZZ | Extirpation of Matter from Left Vitreous, Percutaneous Approach | Core vitrectomy, left eye |
| 08NK3ZZ | Release of Right Retina, Percutaneous Approach | Membrane peeling / retinal release, right eye |
| 08NL3ZZ | Release of Left Retina, Percutaneous Approach | Membrane peeling / retinal release, left eye |
| 08QK3ZZ | Repair of Right Retina, Percutaneous Approach | Retinal reapproximation / repair, right eye |
| 08QL3ZZ | Repair of Left Retina, Percutaneous Approach | Retinal reapproximation / repair, left eye |
| 08DK3ZZ | Extraction of Right Retina, Percutaneous Approach | Retinectomy (excision of retinal tissue), right eye |
| 08DL3ZZ | Extraction of Left Retina, Percutaneous Approach | Retinectomy, left eye |
| 08RK3JZ | Replacement of Right Retina with Synthetic Substitute, Percutaneous Approach | If retinal substitute material is used |
| 08P53JZ | Removal of Synthetic Substitute from Right Vitreous, Percutaneous Approach | If silicone oil or other implant in situ from prior surgery |
| 06T10ZZ | Resection of Right Internal Jugular Vein, Open Approach | (Not applicable — verify correct PCS for scleral buckle) |
| 08UK3JZ | Supplement Right Retina with Synthetic Substitute, Percutaneous Approach | Scleral buckling material supplement |
| 08UK3KZ | Supplement Right Retina with Nonautologous Tissue Substitute, Percutaneous Approach | If donor tissue used in repair |
ICD-10-PCS Root Operation Selection — Critical Guidance:
- Extirpation (C) — used for vitrectomy (removal of vitreous matter, the solid/semi-solid material from within the eye); root operation = taking or cutting out solid matter from a body part; the vitreous gel is the “solid matter” being removed
- Release (N) — used for membrane peeling, delamination, and segmentation; root operation = freeing a body part from abnormal physical constraint; epiretinal and subretinal membranes constrain the retina; the Release root operation captures the act of freeing the retina from membranous restriction
- Repair (Q) — used for reapproximation of the detached retina to the RPE; root operation = restoring a body part to its normal anatomic structure
- Extraction (D) — used for retinectomy (excision/removal of a portion of the retina by cutting); root operation = pulling or stripping out all or a portion of a body part by the use of force; appropriate when a retinal crescent is removed
- Supplement (U) — may be used when scleral buckle material supplements the existing body part structure; root operation = putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part
In most complex retinal detachment repair cases requiring PVR membrane peeling, a minimum of three ICD-10-PCS codes should be assigned: Extirpation (vitrectomy) + Release (membrane peeling) + Repair (retinal reapposition). If retinectomy is performed, add Extraction. If scleral buckling is placed, add Supplement. Confirm current-year ICD-10-PCS table validity in your facility encoder before finalizing codes.
Coding Examples
Example 1 — PVR Stage C-2 with Failed Prior Scleral Buckle, Right Eye
A 58-year-old male with a history of prior right eye rhegmatogenous retinal detachment repaired with scleral buckling 8 months ago presents with re-detachment of the right eye. Wide-field photography and B-scan demonstrate PVR Stage C-2 with fixed star folds in the inferotemporal quadrant, two fixed retinal folds in the superior quadrant, subretinal bands, and total retinal detachment with the macula off. He is taken to the OR for 25-gauge pars plana vitrectomy. The operative report documents: core and peripheral vitrectomy, posterior hyaloid removal, epiretinal membrane peeling with end-gripping forceps, subretinal membrane removal through a posterior retinotomy, PFCL injection, relaxing retinotomy at 8 o’clock for a foreshortened inferior retinal quadrant, fluid-PFCL-silicone oil exchange with 1000 cs silicone oil tamponade, and confluent endolaser at all retinotomy margins and retinal breaks. The pre-existing scleral buckle is retained.
CPT Code:
- 67113-RT — Repair of complex retinal detachment with vitrectomy (PVR Stage C-2, retinotomy, subretinal membrane removal, silicone oil), right eye
ICD-10-CM:
- H35.371 — Proliferative vitreo-retinopathy with retinal detachment, right eye (principal diagnosis)
- H33.051 — Total retinal detachment, right eye (additional specificity; may be coded as secondary)
- Z98.89 — Other specified postprocedural states (prior scleral buckle in situ)
ICD-10-PCS (Inpatient):
- 08C53ZZ — Extirpation of Matter from Right Vitreous, Percutaneous Approach (vitrectomy)
- 08NK3ZZ — Release of Right Retina, Percutaneous Approach (membrane peeling)
- 08DK3ZZ — Extraction of Right Retina, Percutaneous Approach (retinotomy — retinal tissue manipulation)
- 08QK3ZZ — Repair of Right Retina, Percutaneous Approach (retinal reapposition)
Example 2 — Diabetic Traction Retinal Detachment Involving the Macula, Left Eye
A 52-year-old female with poorly controlled Type 2 diabetes mellitus and a 20-year history of proliferative diabetic retinopathy presents with progressive vision loss in the left eye. Fundus exam and OCT demonstrate a traction retinal detachment involving the macula of the left eye with a complex fibrovascular proliferative membrane spanning from the temporal arcade to the optic disc. She is taken to the OR for 23-gauge pars plana vitrectomy. The operative report documents: core vitrectomy, posterior hyaloid separation, bimanual segmentation and delamination of the dense fibrovascular proliferative membrane overlying the macula and temporal arcade using scissors and forceps, intraoperative bleeding managed with endodiathermy, PFCL injection for retinal stabilization, fluid-air exchange, panretinal endolaser photocoagulation to the peripheral avascular retina, and C3F8 (14%) gas tamponade. No scleral buckle was placed.
CPT Code:
- 67113-LT — Repair of complex retinal detachment with vitrectomy (diabetic traction retinal detachment, bimanual fibrovascular membrane dissection, panretinal endolaser, gas tamponade), left eye
ICD-10-CM:
- E11.352 — Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye (principal diagnosis — preferred combination code over separate H33.42 + E11.9)
- E11.65 — Type 2 diabetes mellitus with hyperglycemia (if documented)
- Z79.4 — Long-term (current) use of insulin (if applicable)
ICD-10-PCS (Inpatient):
- 08C63ZZ — Extirpation of Matter from Left Vitreous, Percutaneous Approach (vitrectomy)
- 08NL3ZZ — Release of Left Retina, Percutaneous Approach (fibrovascular membrane delamination/segmentation)
- 08QL3ZZ — Repair of Left Retina, Percutaneous Approach (retinal reapposition)
HCC Documentation Impact: E11.352 maps to HCC 18 (Diabetes with Chronic Complications) and provides full clinical specificity. By contrast, coding E11.9 (Type 2 DM without complications) + H33.42 (traction detachment, left eye) separately would miss the HCC 18 capture and misrepresent the clinical picture. The combination code is always preferred when the retinal detachment is a direct complication of the diabetes.
Example 3 — Stage 5 Retinopathy of Prematurity, Bilateral
A 28-week premature infant with bilateral Stage 5 ROP presents for surgical intervention. The right eye demonstrates a closed funnel retinal detachment. Under general anesthesia, the neonatologist manages systemic monitoring while the vitreoretinal surgeon performs 27-gauge lens-sparing vitrectomy of the right eye with careful dissection of the retrolental fibrovascular tissue, relaxation of the funnel configuration, fluid-air exchange, and C2F6 gas tamponade. The left eye is managed conservatively at this session.
CPT Code:
- 67113-RT — Repair of complex retinal detachment with vitrectomy (Stage 5 ROP, closed funnel detachment, lensectomy, retinotomy), right eye
ICD-10-CM:
- H35.151 — Retinopathy of prematurity, stage 5, right eye (principal diagnosis)
- H35.153 — Retinopathy of prematurity, stage 5, bilateral (if bilateral ROP is documented even though only one eye operated)
- P07.26 — Extreme immaturity of newborn, gestational age 28 completed weeks (if neonatal admission)
Example 4 — Incorrect Code Selection — Standard Detachment Miscoded as Complex
A 45-year-old male with a fresh, macula-on rhegmatogenous retinal detachment of the left eye with two horseshoe tears at 10 and 2 o’clock, no PVR, no prior surgery, and no complex pathology undergoes 25-gauge PPV with endolaser and C3F8 gas. The surgeon notes “complex procedure due to the posterior location of the breaks” in the operative report and the coder bills CPT 67113.
Incorrect: 67113 — “Complex procedure” based on break location alone does not meet the CPT definition of complex retinal detachment; no qualifying pathology (PVR C-1+, diabetic TRD, ROP, retinoschisis, coloboma, or equivalent) is documented
Correct: 67108 — Standard vitrectomy-based retinal detachment repair; the procedure was technically a standard PPV for RRD without qualifying complex features
Audit Risk Note: Upcoding from 67108 to 67113 based on subjective surgeon characterization of operative difficulty — without documentation of a qualifying complex pathologic condition — is one of the highest audit risk coding practices in vitreoretinal surgery. The CMS Recovery Audit Contractors (RACs) and commercial payer audit programs specifically target 67113 claims and will request operative reports. If the operative report does not document PVR (with stage), diabetic TRD, ROP, retinoschisis, coloboma, or equivalent complex pathology, the claim will be denied and recouped. The wRVU difference between 67113 and 67108 (~7.84 wRVU) makes this a high-dollar audit target.
Example 5 — PVR Discovered Intraoperatively After Pre-Operative Billing Planning
A 61-year-old female is scheduled for vitrectomy-based retinal detachment repair. Pre-operative assessment suggests a straightforward RRD and the case is planned as a 67108. Intraoperatively, the surgeon encounters Grade C-2 PVR with fixed star folds requiring membrane peeling, PFCL, retinotomy, and silicone oil. The operative report documents these findings and techniques in detail.
CPT Code:
- 67113 — despite pre-operative planning as 67108, the intraoperative findings and techniques performed support 67113; CPT code selection is based on what was actually performed and documented, not on pre-operative planning
Key Coding Principle: CPT code selection must reflect the procedure actually performed and documented in the operative report. Pre-operative authorization for 67108 does not preclude billing 67113 when intraoperative findings change the operative course. The surgeon should document the unexpected findings and the clinical decision to perform the additional complex maneuvers. A prior authorization appeal or notification to the payer may be warranted, but the billing code must match the operative reality.
Example 6 — Sequential Staged Procedures — Oil Removal After 67113
A 55-year-old male had complex PVR retinal detachment repair of the right eye with silicone oil tamponade (CPT 67113) 4 months ago. The retina is stable and attached. He returns for silicone oil removal.
CPT Code (at oil removal session):
- 67121-RT — Removal of implanted material from posterior segment; intravitreal (silicone oil removal)
Modifier Consideration: The oil removal occurs after the 90-day global period of the original 67113 repair (90 days from the original surgery date), so no modifier is needed for global period overlap. If the removal were within the global period — which would be uncommon for oil removal but possible — modifier -58 (staged procedure) would be appended.
ICD-10-CM:
- H35.371 — Proliferative vitreo-retinopathy with retinal detachment, right eye (or H33.001 if PVR has resolved and it is now coded as residual detachment status)
- Z98.89 — Other specified postprocedural states (silicone oil in situ from prior surgery)
Documentation Requirements
To support CPT 67113, the operative report must unambiguously document the following:
-
Qualifying complex condition — explicitly identify and name the specific complex pathology present (e.g., “PVR Stage C-2 with fixed star folds,” “diabetic traction retinal detachment secondary to proliferative diabetic retinopathy,” “Stage 5 ROP with closed funnel detachment,” “retinoschisis with associated retinal detachment”); vague language such as “complex detachment” or “difficult case” without specific pathology is insufficient
-
Laterality — specify right eye, left eye, or bilateral; include which specific retinal region, quadrant(s), or clock hours are involved
-
Vitrectomy — confirm that pars plana vitrectomy was the operative approach; document gauge (23g, 25g, 27g), ports used, and completeness of vitreous removal including peripheral vitreous base shaving
-
Advanced techniques employed — document which specific advanced techniques were performed and why (e.g., “extensive epiretinal membrane peeling performed to relieve tractional forces from PVR Stage C-2 fixed folds,” “bimanual delamination of fibrovascular proliferative membrane in diabetic TRD,” “retinotomy performed at 7 o’clock due to inability to flatten retina after complete membrane removal”)
-
PFCL use — if perfluorocarbon liquid was used, document injection and complete removal
-
Tamponade agent — document the specific tamponade used (silicone oil 1000 cs, silicone oil 5000 cs, C3F8, C2F6, SF6, air) and the clinical rationale for selection
-
Endolaser application — document locations treated, technique (focal, panretinal, at retinotomy/retinectomy margins), and the number of burns or area covered
-
Cryotherapy — if used, document location, technique, and indication
-
Scleral buckle — if placed, document type (segmental vs. encircling), element number (e.g., 240 band), and suturing technique
-
Lens removal — if performed, document technique (lensectomy, phacoemulsification) and whether an IOL was placed; state the clinical indication for lens removal (access to posterior segment, cataractous lens, ROP funnel)
-
Intraoperative complications — document any intraoperative events such as hemorrhage, iatrogenic retinal breaks, or choroidal effusion, and the technique used to manage them
-
Pre-operative assessment — document pre-operative fundus exam findings, PVR grade/stage using a recognized classification system, visual acuity, macular status, and prior surgical history
Clinical Notes for Coders
-
PVR staging documentation is essential and must be explicit. The CPT descriptor specifies “PVR Stage C-1 or greater.” If the surgeon does not document the PVR stage, or documents only “PVR present” without staging, 67113 may not be supportable. Query the surgeon for the PVR stage using the Retina Society Classification (or equivalent current classification) when PVR is mentioned without grading.
-
Diabetic TRD is explicitly named in the CPT descriptor. This is arguably the most clinically common indication for 67113 in the adult population given the global prevalence of Type 2 diabetes mellitus. Any well-documented diabetic traction retinal detachment repaired with vitrectomy is appropriate for 67113, regardless of whether additional complex techniques (PFCL, retinotomy) were employed. The diabetic TRD itself is the qualifying condition.
-
Retinotomy vs. retinectomy — both represent advanced, high-complexity intraoperative decisions that independently support the use of 67113. A retinotomy is an incision into the retina; a retinectomy involves excision of retinal tissue. Either, when performed as part of complex retinal detachment repair, strongly documents operative complexity beyond the scope of 67108.
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Silicone oil alone does not define 67113. Silicone oil is also used in CPT 67108 cases (it is explicitly included in the 67108 descriptor as an allowable tamponade). The presence of silicone oil does not elevate a 67108 case to 67113. The qualifying complex pathology — not the tamponade agent — determines code selection.
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Re-detachment during the global period of a prior 67108 repair that now requires complex repair qualifying for 67113 presents a modifier challenge. A return to the OR within 90 days for a re-detachment related to the original repair is reported with modifier -78 (unplanned return to OR for complication). If the new surgery is CPT 67113 and the original was CPT 67108, append -78 to 67113 and expect reduced reimbursement (payment is at 70% of the surgical fee when -78 is applied by Medicare for a return within the global period).
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Bilateral simultaneous complex retinal detachment repair is exceptionally rare in adults (though more common in neonatal ROP surgery). If performed, report each eye separately with -RT and -LT laterality modifiers. Do not use modifier -50 for bilateral eye procedures — use laterality modifiers and separate line items.
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Prior authorization considerations: Given the substantially higher reimbursement of 67113 vs. 67108, many payers require prior authorization or intraoperative documentation (such as a retinal diagram or fundus photograph documenting PVR stage) to support 67113. Practices performing vitreoretinal surgery should have a documentation protocol that includes pre-operative fundus photography, B-scan when indicated, and operative diagrams or RetCam images in pediatric ROP cases.
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Global period management: The 90-day global period for 67113 includes all routine post-operative visits for the repaired retinal detachment. Post-operative visits for the contralateral eye, for unrelated conditions, or for new complications requiring a return to the OR are not included in the global package. If silicone oil removal (67121) is anticipated and may fall within the 90-day global period of 67113 (unusual but possible in rare cases of early oil removal for complications), modifier -58 (staged related procedure) must be appended to 67121 to allow separate reimbursement.