Clinical Context
A 68-year-old patient presents with progressive vision loss and metamorphopsia in the affected eye over several months. Clinical exam and optical coherence tomography demonstrate an epiretinal membrane (macular pucker) with traction on the macula and resulting decreased visual acuity. The retina specialist recommends pars plana vitrectomy with membrane peeling to remove the epiretinal scar tissue and release traction. The patient is prepared for an outpatient ophthalmic surgical procedure under monitored anesthesia care or general anesthesia depending on comorbidities and surgeon preference. Intraoperative steps typically include creation of three pars plana sclerotomies, removal of vitreous humor with a vitreous cutter to gain access to the retinal surface, staining and peeling of the epiretinal membrane, and fluid–air exchange or tamponade if indicated. Postoperative workflow includes same-day recovery, short-term topical antibiotics and steroids, scheduled follow-up visits to monitor retinal attachment and visual recovery, and documentation of preoperative consent, operative report describing removal of vitreous and membrane peeling, and anesthesia records. Typical site of service is an ambulatory surgical center or hospital outpatient department specializing in ophthalmic surgery.
Coding Specifications
| Modifier | Description | When to Use |
|---|
59 | Distinct procedural service | Use when a separate, distinct procedure is performed on the same day that is not normally reported together with vitrectomy and meets documentation requirements. |
| 62 | Two surgeons | Use when two surgeons work together as primary surgeons performing distinct portions of the vitrectomy/membrane peel.
| 66 | Surgical team | Use when multiple clinicians function as a surgical team and team reporting is appropriate.
| 76 | Repeat procedure by same physician | Use if the identical vitrectomy/membrane peel is repeated by the same provider during the postoperative global period (note: 76 is not in provided list; excluded).
| 80 | Assistant surgeon | Use when an assistant surgeon is required and reports an assistant's portion of the procedure.
| 81 | Minimum assistant surgeon | Use when minimal assistance is documented.
| 22 | Increased procedural services | Use when intraoperative complexity or difficulty is greater than usual and adequately documented.
| 52 | Reduced services | Use when the procedure is partially reduced or not completed as planned.
| 53 | Discontinued procedure | Use when the vitrectomy is started but discontinued for patient safety reasons.
| 74 | Discontinued outpatient hospital/ASC procedure prior to anesthesia induction | Use if procedure is cancelled after patient is prepared but before induction (specific to outpatient setting).
| 78 | Return to OR for a related procedure during the postoperative period | Use when a return to the operating room is required for a related complication.
| 79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period.
| 26 | Professional component | Use when only the professional interpretation or physician component is reported (rare for surgical services).
| TC | Technical component | Use when only the technical component is billed (e.g., facility billing for equipment/operating room resources).
| RT / LT | Right / Left side | Use to indicate laterality of the operated eye.
| Taxonomy Code | Specialty | Notes |
|---|
| 207W00000X | Ophthalmology | Retinal surgery and vitreoretinal specialists commonly perform 67041. |
| 207WP2300X | Retina/Vitreous Specialist | Subspecialty focused on vitreoretinal surgery and membrane peeling.
| 2084P0800X | Anesthesiology | Provides monitored anesthesia care or general anesthesia for ophthalmic procedures.
| 208D00000X | Ophthalmic Assistant/Technician | Perioperative support staff involved in ASC or hospital ophthalmic procedures.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
H35.34 | Epiretinal membrane | Primary indication for pars plana vitrectomy with membrane peeling to relieve macular traction and improve vision. |
| H35.30 | Macular puckering, unspecified | Clinical term often used interchangeably with epiretinal membrane; indicates the target lesion.
| H33.4 | Traction detachment of retina | May coexist with membrane-related traction; vitrectomy and membrane peel can address tractional components.
| H33.3 | Retinal detachment, unspecified | Retinal tears or detachments identified pre- or intraoperatively may alter surgical plan and require additional repair.
| H43.8 | Other disorders of vitreous body | Vitreous opacities or hemorrhage that necessitate vitrectomy to clear media for membrane access.
| H54.7 | Visual impairment, unspecified | Describes functional deficit prompting surgical intervention when attributable to epiretinal membrane.
| E11.9 | Type 2 diabetes mellitus without complications | Diabetes is commonly present in the surgical population and increases risk for tractional changes and complications.
| I10 | Essential (primary) hypertension | Common comorbidity relevant to perioperative management and anesthesia risk.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
67036 | Vitrectomy, pars plana; removal of vitreous (partial) | Often performed when vitreous removal alone is indicated; may be billed for core vitrectomy steps if membrane peeling is not performed. |
| 67042 | Vitrectomy, pars plana; with removal of preretinal membrane, internal limiting membrane peel (separate technique) | Performed when both epiretinal membrane and internal limiting membrane are peeled; relates directly when more extensive peeling is required.
| 67121 | Repair of retinal detachment, pneumatic retinopexy or scleral buckling (external) (list may vary) | May be required if retinal detachment is present or occurs as a complication; represents alternate or adjunctive retinal procedures.
| 66250 | Repair of retinal tear with cryotherapy | Often used in the same surgical episode if retinal tears are identified and treated intraoperatively.
| 67039 | Vitrectomy, pars plana; with removal of vitreous, with or without membrane peel, complex | Used for more complex vitrectomy procedures when additional intraoperative complexity or techniques are required.
| 66984 | Cataract extraction with intraocular lens implantation (phacoemulsification) | Frequently performed concurrently in combined cataract and vitrectomy cases in phakic patients to improve visualization and outcome.