Summary & Overview

CPT 67042: Pars Plana Vitrectomy with Internal Limiting Membrane Peel

CPT code 67042 represents a pars plana vitrectomy with removal of the internal limiting membrane of the retina, a surgical intervention used to treat macular pathology such as macular edema and macular holes. This procedure can include insertion of adjunctive agents — air, gas, or silicone oil — to stabilize the retina during or after the repair. Nationally, vitrectomy procedures are clinically significant due to their role in vision preservation and the high resource intensity of operating-room-based retinal surgery.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and service settings, typical sites of service, and commonly reported modifiers associated with billing for this procedure. The publication provides benchmarks and policy-context information relevant to coverage and reimbursement for posterior-segment ophthalmic surgery, notes on coding scope for membrane peeling and intraocular tamponade, and practical billing considerations for facility and professional claims.

This summary is written for a national audience and is intended to clarify what CPT code 67042 represents, who commonly pays for these services, and what operational and coding topics to expect in the full publication.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare67042CPTvitrectomyretinamacular-holeophthalmologysurgical-procedureambulatory-surgery

Billing Code Overview

CPT code 67042 describes a pars plana vitrectomy with removal of the internal limiting membrane of the retina. In this procedure, the provider removes the vitreous humor using a mechanical cutting tool and excises the internal limiting membrane to treat macular conditions such as macular edema or a macular hole. The description notes that the provider may also inject air, gas, or silicone oil to stabilize the retina.

Service type: Posterior segment surgical ophthalmology procedure (pars plana vitrectomy with membrane peeling)
Typical site of service: Ambulatory surgical center or hospital outpatient department (operating room for ophthalmic surgery)

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 68-year-old patient presents with progressive central vision distortion and decreased visual acuity in one eye, consistent with a full-thickness macular hole with associated vitreomacular traction and cystoid macular edema. The ophthalmologist performs a pars plana vitrectomy with removal of the internal limiting membrane to relieve traction and allow macular hole closure. The procedure includes removal of the vitreous gel using a mechanical cutter, membrane peeling with microforceps and dye-assisted visualization, and intraocular tamponade with a long-acting gas (e.g., sulfur hexafluoride) to support retinal apposition during postoperative positioning. Typical workflow steps: preoperative evaluation with optical coherence tomography (OCT) and retinal exam; informed consent; anesthesia (local retrobulbar or monitored anesthesia care); operative vitrectomy with ILM peel and fluid–gas exchange or silicone oil placement if indicated; immediate postoperative instructions for head positioning and activity restrictions; scheduled follow-up visits with OCT to assess macular hole closure and intraocular pressure monitoring. Typical site of service is an ambulatory surgery center or hospital outpatient operating room for ophthalmic surgery.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when reporting only the physician’s professional component separate from the technical facility component, if applicable for imaging or intraoperative interpretation services.
`50`	Bilateral procedure	Use when the same vitrectomy procedure is performed on both eyes during the same operative session.
`51`	Multiple procedures	Use when other distinct ophthalmic procedures are performed during the same operative session (report primary CPT and append `51` to additional procedures per payer rules).
`52`	Reduced services	Use when the vitrectomy is partially reduced or not completed as described (e.g., aborted for unstable patient).
`53`	Discontinued procedure	Use when the procedure is started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct parts of the same vitreoretinal procedure.
`66`	Surgical team	Use when a surgical team participates (multiple qualified surgeons with defined roles) in complex vitreoretinal surgery.
`78`	Unplanned return to the operating room for a related procedure during the postoperative period	Use when the patient requires an unplanned reoperation related to the initial vitrectomy (e.g., re-tamponade).
`79`	Unrelated procedure or service by the same physician during the postoperative period	Use when an unrelated procedure is performed in the global period.
`22`	Increased procedural services	Use when the vitrectomy requires substantially greater work than typical (e.g., complex membrane dissection, extensive hemorrhage control).

Taxonomy Code	Specialty	Notes
207RX0200X	Ophthalmology	Retinal surgeons and vitreoretinal subspecialists commonly perform `67042` procedures.
207RX0000X	Ophthalmology — General	General ophthalmologists with surgical privileges may perform pars plana vitrectomy for select cases.
2080P0205X	Anesthesiology	Provides monitored anesthesia care or regional/local anesthesia for ophthalmic procedures.
207L00000X	Ophthalmic Plastic & Reconstructive Surgery	May be involved when combined orbital/eyelid procedures occur with vitreoretinal surgery (less common).

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H35.81`	Macular hole	Primary indication for pars plana vitrectomy with ILM peel to promote closure and restore macular anatomy.
`H33.4`	Retinal detachment with macular involvement	May necessitate vitrectomy with internal tamponade to reattach the retina and address macular pathology.
`H35.3`	Cystoid macular edema	ILM peeling and vitrectomy may be performed when persistent or tractional CME is associated with vitreomacular interface disease.
`H35.39`	Other macular disorders	Includes degenerative or tractional maculopathies where vitrectomy and membrane peel are indicated.
`H44.01`	Vitreous hemorrhage, right eye	Vitrectomy is commonly performed to clear nonresolving vitreous hemorrhage and address underlying causes such as retinal tears.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`67036`	Vitrectomy, pars plana; removal of vitreous gel only	Often performed for diagnostic or therapeutic vitrectomy without ILM peel; may be performed in combination or as a staged procedure relative to `67042`.
`67041`	Vitrectomy, pars plana; with removal of internal limiting membrane (ILM) — bilateral or unilateral (alternate code for different documentation/reporting contexts)	Closely related vitrectomy code; used when documentation meets specific code descriptors distinct from `67042`.
`67043`	Vitrectomy, pars plana; with removal of epiretinal membrane (with or without ILM peel)	Performed when an epiretinal membrane is the primary target; may be performed in same session if present with macular hole.
`67121`	Scleral buckling procedure or retinal detachment repair — complex; repair of rhegmatogenous retinal detachment with vitrectomy and internal tamponade	Performed when a retinal detachment is present or develops, often requiring combined vitrectomy and additional retinal repair techniques.
`67010`	Drainage of retinal fluid or subretinal fluid; retinal detachment procedures (diagnostic)	May be performed in the workup or in conjunction with retinal procedures when subretinal fluid drainage is required.
`66982`	Extracapsular cataract removal with insertion of intraocular lens (complex)	Cataract surgery is commonly performed concurrently or prior to vitrectomy in older patients to improve visualization and outcomes; combined procedures are common in practice.