The process of removing silicone oil following a complex retinal detachment typically occurs one of two ways: via vitrectomy; or aspiration without a vitrectomy. We receive periodic questions about the correct coding for this procedure. We are also asked about what ICD-10 code applies and if a modifier is needed. Here, we review those issues and provide direction. 

 

The Correct CPT Code

There is ongoing confusion regarding the correct code to use to describe the removal of silicone oil. Retina specialists use silicone oil in cases of a chronic retinal detachment, proliferative vitreoretinopathy (scarring), advanced cases of diabetic retinopathy, macular holes and other disease processes that require long-term tamponade of the retina following vitrectomy. Silicone oil is injected into the eye following the vitrectomy and left in the eye until the surgeon determines the retina is stable. 

The two most common codes used for removal of oil, without treatment of other pathology, are 67036 and 67121. The Current Procedural Terminology (CPT) Manual defines the two codes as:

  • 67036 – Vitrectomy, mechanical, pars plana approach; and 
  • 67121 – Removal of implanted material, posterior segment; intraocular.

The question we receive is “Which CPT code best describes the work performed to remove the silicone oil?” When the situation is straightforward and removing the oil is the only procedure completed, the coding is easily determined by examining the technique the surgeon describes in the operative report. If the surgeon employs a pars plana vitrectomy to remove the oil, CPT 67036 is used. Conversely, if the surgeon removes the oil with aspiration and does not use the vitrector, consider 67121.  

 

Coding Complicated Cases

However, patients are often more complicated, and the answers can vary with respect to CPT, diagnosis coding and modifiers. The rationale and timing for oil removal can help determine what ICD-10 code to use and the need for a modifier. Consider the following questions:

  • Is oil removal a second stage of the primary procedure?
  • Does a new problem necessitate the oil removal?
  • Did the oil cause a complication for which removal is the solution?
  • Is there a secondary problem (comorbidity)? If yes, is it complicated by the oil?
  • Is the oil being removed in the global period of the retinal detachment repair?

The following four examples will shed some light on the best ICD-10 code and the need for any modifiers.  

 

Example 1: Staged Procedure

Surgeons often plan to remove the oil as the eye approaches stability. However, the eye doesn’t reach stability until completion of the final staged procedure—silicone oil removal. From the patient’s perspective, the presence of silicone oil causes poor vision and is undesirable. The appropriate diagnosis code for the staged vitrectomy (or aspiration) to remove the silicone oil is the original diagnosis from the primary procedure. 

Conflict and misunderstandings arise when chart notes (during the postoperative period of the primary procedure) state “retina stable” or “retina flat,” as if a satisfactory endpoint has been reached. The retina appears flat with an imperfect view through the oil when, in actuality, the treatment of the primary problem is neither complete nor successful until the oil is removed. 

If the oil removal occurs during the postoperative period, append modifier -58 (staged procedure) to the procedure code. This modifier is unnecessary if removal takes place outside the 90-day postoperative interval, although the concept of a staged procedure still applies. The appropriate CPT codes are likely 67036 or 67121.

 

Example 2: New Condition

The patient returns four months after vitrectomy of the right eye with placement of silicone oil. The patient has developed a new epiretinal membrane. The surgeon recommends vitrectomy with ERM stripping as well as removal of silicone oil. The ICD-10 code H35.371 (Puckering of macula, right eye) is used on the claim. The silicone oil is removed during the vitrectomy/membrane peel, which is reported by CPT 67041 (PPV with removal of preretinal cellular membrane), so no separate charge is made for removal of the oil.  

If the ERM stripping occurred during the 90-day global period, modifier -79 would apply since the procedure and condition are unrelated to the initial procedure. In addition, the ERM may have developed regardless of the oil.

 

Example 3: Recurrent Condition

The patient had a retinal detachment with proliferative vitreoretinopathy. The surgeon performed a vitrectomy with membrane stripping with injection of silicone oil (CPT 67113). The patient recovered nicely, although the oil remained in the eye. Now, the patient presents with a recurrent retinal detachment and proliferative vitreal retinopathy four months postoperatively. The surgeon recommends another vitrectomy with membrane stripping.  

Use the appropriate RD ICD-10 code (H33.-) along with CPT 67113. As in the second example, there’s no additional charge for the oil removal. If the recurrent RD develops during the 90-day global period, modifier -78 applies since the procedure and condition are related and the coding for the initial procedure was 67113.  

 

Example 4: Complication

The patient develops a complication from the silicone oil, such as a spike in intraocular pressure not controlled with medical therapy, so the oil needs to be removed. While it may be tempting to use the same diagnosis as the primary procedure, as in the first example, the reason for removing the oil is the IOP spike secondary to its appropriate use, not the aforementioned retinal problem. According to ICD-10, an ocular surgical complication from an implant is coded as T85.398 (Other mechanical complications of other ocular prosthetic devices, implants and grafts). Any applicable secondary ICD-10 codes would also apply.

 

Conclusion and Further Reading

If only oil is being removed, the CPT coding is obvious. However, when considering other factors, such as global periods, complications, recurrence, comorbidities and/or new problems, the answers become complicated. Take your time and consider these scenarios to reach the correct answer. For a more detailed discussion regarding reimbursement for surgical procedures during the postoperative period, see the article “Avoiding Post-Surgical Modifier Confusion” (Retina Specialist, December 2017; available here ).

 

Mr. Mack is a senior consultant with Corcoran
Consulting Group. He can be reached at 1-800-399-6565 or at www.corcoranccg.com.