Crystal's MCW Coder Hub⚕️CPT Code 67145: Prophylactic treatment of retina; extensive
Code Description
CPT 67145 describes the prophylactic treatment of the retina, such as laser photocoagulation, when the treatment is considered extensive. This procedure is typically performed to prevent retinal detachment or other vision-threatening complications in eyes at high risk, rather than to treat an existing detachment or active lesion.
The term “extensive” is not strictly defined by a specific number of laser spots in the CPT manual but is generally determined by the physician’s judgment based on the surface area treated, the number of sessions required, and the complexity of the pathology (e.g., extensive lattice degeneration, multiple retinal tears without detachment, or high-risk fellow eyes).AMA CPT 2024
Note:
67145 is a CPT procedure code. Metrics such as wRVU and Assistant Payable status apply to procedural coding. HCC risk adjustment applies only to diagnosis codes (ICD-10-CM).
Hierarchical Condition Category (HCC)
- HCC Status: Not Applicable
- Reasoning: HCC (Hierarchical Condition Category) models are used for risk adjustment based on patient diagnoses (ICD-10-CM), not procedures.
- Related Diagnosis Impact: The underlying diagnosis driving the necessity of 67145 (e.g., H33.31 Retinal tear without detachment) may carry HCC weight for Medicare Advantage risk adjustment. Chronic conditions like Diabetic Retinopathy (E11.319) often carry higher HCC risk scores than prophylactic retina codes.CMS HCC Model Documentation
Financial & Billing Metrics
| Metric | Value | Notes |
|---|---|---|
| wRVU | 1.57 | Work Relative Value Unit (2024 Medicare Physician Fee Schedule). Subject to annual update and geographic adjustment. |
| Total RVU (Non-Fac) | 2.63 | Includes Work, Practice Expense, and Malpractice components in office setting. |
| Total RVU (Fac) | 1.79 | Includes Work, Practice Expense, and Malpractice components in facility setting. |
| Assistant Payable | Yes | Assistant at Surgery Indicator: 1 (Payment allowed for assistant surgeon). |
| Global Period | 0 Days | Post-operative period is 0 days; E/M services on the day of procedure may be billed if significant and separately identifiable (Modifier 25). |
| Facility Pricing | Yes | Typically performed in Office or Ambulatory Surgery Center (ASC). |
| Non-Facility Pricing | Yes | Commonly performed in office-based laser rooms. |
Official Coding Guidelines
Includes
- Prophylactic laser photocoagulation.
- Treatment of lattice degeneration.
- Treatment of retinal tears without detachment.
- Treatment of high-risk fellow eyes.
- Extensive treatment (physician judgment based on scope/area).
- One or more sessions (code covers the course of treatment defined as extensive).
Excludes / Parenthetical Notes
- Less than Extensive: If the treatment is not extensive, report 67141 instead.
- Destruction of Lesions: Do not use 67145 for the destruction of localized lesions (e.g., tumors, specific neovascularization). Use destruction codes such as:
- Retinal Detachment: If the patient has an existing retinal detachment, prophylactic codes are generally inappropriate; repair codes (e.g., 67101-67113) should be used.AMA CPT 2024
Modifiers
- 50: Bilateral Procedure (If performed on both eyes during the same session).
- RT / LT: Right Eye / Left Eye (Required by most payers for ophthalmic codes).
- 59: Distinct Procedural Service (If performed with another unrelated procedure on the same day).
- 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician (If an E/M visit occurs on the same day as the laser).
- 76: Repeat Procedure by Same Physician (If extensive treatment requires multiple distinct sessions billed separately under specific payer rules, though CPT says “one or more sessions”).
MS-DRG and APC Assignment
- MS-DRG (Inpatient): Not Applicable
- Reasoning: MS-DRGs are assigned based on ICD-10-PCS procedure codes for inpatient hospital stays. 67145 is a CPT code used for physician/outpatient billing.
- Inpatient Equivalent: If performed inpatient, hospital coding will use ICD-10-PCS (e.g., Photocoagulation of Retina).
- APC (Outpatient): Applicable
- System: Ambulatory Payment Classification (APC) under the Hospital Outpatient Prospective Payment System (OPPS).
- Status Indicator: Typically Status Indicator S (Significant Procedure, not reduced when multiple).
- Associated APC: Often maps to APC 5493 (Level 3 Retina Procedures) or similar depending on the year’s update.CMS OPPS Final Rule
Code Tree (Hierarchy)
The following hierarchy illustrates the placement of 67145 within the CPT structure:
- Section: Surgery
Coding Examples
Example 1: Extensive Lattice Degeneration
- Scenario: A patient with high myopia is found to have extensive lattice degeneration with thinning in the superior and temporal quadrants of the left eye. The physician performs barrier laser photocoagulation around the extensive areas to prevent retinal detachment.
- CPT Code: 67145-LT
- ICD-10-CM: H33.323 (Lattice degeneration of retina, left eye)
- Rationale: The treatment is prophylactic and covers extensive areas, qualifying for 67145 over 67141.AAO Coding Expert
Example 2: Multiple Retinal Tears Without Detachment
- Scenario: A patient presents with flashing lights. Examination reveals three horseshoe tears in the right eye without evidence of subretinal fluid or detachment. The physician lasers all three tears and the surrounding retina extensively.
- CPT Code: 67145-RT
- ICD-10-CM: H33.311 (Retinal tear without detachment, right eye)
- Rationale: Multiple tears requiring extensive barrier laser fit the description of 67145.
Example 3: Exclusion Scenario (Existing Detachment)
- Scenario: The patient has a retinal tear with a small amount of subretinal fluid indicating a localized detachment. The physician performs laser retinopexy.
- CPT Code: 67105 (Repair of retinal detachment; photocoagulation)
- ICD-10-CM: H33.001 (Unspecified retinal detachment with retinal break, right eye)
- Rationale: Because a detachment exists, prophylactic codes (67145) are incorrect. Repair codes must be used.AMA CPT 2024
Clinical Documentation Improvement (CDI) Tips
- Extensive vs. Less Than Extensive: The medical record should support why the treatment is “extensive.” Document the number of quadrants treated, the number of laser spots, or the complexity of the pathology (e.g., “360 degrees of lattice”).
- Prophylactic Intent: Clearly document that the treatment is prophylactic (preventative). If the intent is to treat an existing detachment or active neovascularization, different codes apply.
- Laterality: Always document which eye(s) were treated to ensure correct modifier usage (RT, LT, or 50).
- Session Definition: CPT states “one or more sessions.” If treatment is split over days, clarify with payer policy if 67145 is billed once per course or per session. Generally, it is billed per eye per course of treatment defined as extensive.AAO Coding Expert
Related Codes
- 67141: Prophylactic treatment of retina; less than extensive
- 67210: Destruction of retinal lesion, one or more sessions; cryotherapy
- 67218: Destruction of retinal lesion, one or more sessions; photocoagulation
- 67220: Destruction of retinal lesion, one or more sessions; photocoagulation, extensive
- 67221: Destruction of retinal lesion, one or more sessions; photocoagulation, extensive with treatment of extensive retinal detachment
- 67105: Repair of retinal detachment; photocoagulation
- H33.31: Retinal tear without detachment
- H33.32: Lattice degeneration of retina
- H33.5: Other retinal detachments
AMA CPT 2024 Professional Edition CMS Medicare Physician Fee Schedule 2024 CMS OPPS Final Rule 2024 American Academy of Ophthalmology Coding Expert CMS HCC Risk Adjustment Model Documentation