A year ago, in The Ophthalmic ASC May 2020 issue, I presented a column titled, “2020 Retina/Vitreous Coding Conundrums for Silicone Oil Removal.”¹ No progress has been made in establishing a Current Procedural Terminology (CPT) code or a revision of one, and so the conundrum remains. It’s the same for removal of silicone oil in either the anterior or posterior segment: There is no specific CPT code for the surgery, nor have examples been officially amended to include removal of anything other than intraocular lenses.

In this review, some practical coding principles are presented, along with suggested coding solutions. Using a specifically named instrument does not necessarily equate to a given surgical procedure: e.g., using a vitrector does not equate to having performed a vitrectomy. As a Medicare specialist, the guidelines suggested in this article are those of CMS and may not reflect policies of other insurers.

SILICONE OIL REMOVAL AFTER MIGRATION INTO THE ANTERIOR CHAMBER

Paracentesis code descriptors for CPT codes 65800 and 65810 (often described as anterior chamber washout) are sometimes descriptive of the procedure, whereas at other times other CPT codes, such as 65920 (Removal of implanted material, anterior segment of eye), may be more appropriate.

The techniques most commonly found are listed in Table 1. It is important to select the CPT code that accurately describes the surgical technique employed.

SILICONE OIL REMOVAL AND REPLACEMENT DURING SECONDARY VITREO-RETINAL SURGERY PROCEDURES

Recurrent retinal detachment repair often involves removal of the previously inserted silicone oil with secondary insertion of new silicone oil. As a general rule, the procedures for removal may be safely coded; however, the CPT codes for the secondary insertion are often bundled with the primary procedure, such as 67113 (complex retinal detachment repair) in the National Correct Coding Initiative (NCCI), and are therefore not eligible for reimbursement by Medicare. Each insurer will have its own rules.

The CPT codes describing paracentesis are most often bundled in the NCCI when coding more complicated surgeries.

CASE EXAMPLE

EXCERPTS FROM THE OPERATIVE NOTES
(Extracted by the author)

A paracentesis was made at 9 o’clock and a 25-gauge MVR blade was used to lyse the adhesions between the iris and the pupillary membrane. Iris hooks were used to retract the iris.

The vitrector was placed in the anterior chamber and used to remove the membrane, and also used to create an iridotomy at 6 o’clock. The retained silicone oil was removed from the anterior chamber using the vitrector.

Closed posterior vitrectomy was performed. There was extensive pre-retinal proliferation, with detachment of the anterior retina 360° up to the posterior equator. The membranes were extremely dense. There were several retinal breaks with a large retinal break temporally. The posterior retina, and specifically the macula, were attached.

The membranes were elevated and cut with the vitrector where possible. An anterior retinectomy was performed to relieve the traction on the retina. Endolaser was applied 360° to the edges of the attached retina.

Further vitrectomy and subsequent air/fluid exchange were performed.

The vitreous cavity was filled to the level of the lens with 5000 CS silicone oil.

TIPS:

• For Medicare coding, it is best to limit the CPT codes to five, as that is the number of codes that may be used before the claim is rejected from automatic processing and sent for individual consideration by an expert. This can result not only in prolonged delays in payment, but also possibly lesser reimbursement.
• The complex retinal detachment repair CPT code (67113) is bundled with many other codes, because it is considered all-inclusive. I recommend choosing unbundled codes since excessive use of modifier 59 is an ongoing audit trigger.
• If you are simply removing silicone oil as a stand-alone procedure because its presence is no longer deemed necessary in the eye, you can use modifier 58 that is reimbursed at 100% of the allowable rather than 70% of the allowable that is paid for using modifier 78. Modifier 79 is not applicable. ■

CPT codes copyrighted by the American Medical Association 2020

REFERENCES

1. Asbell, R.L. 2020 Retina/Vitreous Coding Conundrums for Silicone Oil Removal. The Ophthalmic ASC. May, 2020.
2. Asbell, R.L. Coding Reassessment for Complex Retinal Detachment Repair. New Retina Physician (supplement to Ophthalmology Management). September, 2018.