Summary & Overview
CPT 67043: Pars Plana Vitrectomy with Subretinal Membrane Removal
CPT code 67043 represents a pars plana vitrectomy with removal of subretinal membrane, a surgical retinal procedure used to address vision-obstructing neovascular membranes and subretinal fibrosis often seen with age-related macular degeneration. Nationally, this code captures a high-complexity ophthalmic operative service with implications for surgical resource utilization, facility billing, and payer coverage policies for retinal disease treatments. Key payers commonly involved in coverage and reimbursement for this service include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find a concise overview of clinical indications and the operative components coded by CPT code 67043, plus benchmarks and policy-relevant context about payer handling and coverage considerations. The publication outlines typical settings where the service is performed — ambulatory surgical centers and hospital operating rooms — and summarizes common clinical adjuncts such as intraocular tamponade (air/gas/silicone oil) and intraoperative laser use. Where available, benchmarking data and payer policy trends are presented to help administrators and clinicians understand utilization patterns, billing complexity, and areas to monitor for prior authorization or coding integrity. Data not available in the input will be noted as such in detailed sections.
Billing Code Overview
CPT code 67043 describes a pars plana vitrectomy with removal of subretinal membrane to treat neovascularization and subretinal fibrosis commonly associated with age-related macular degeneration. The procedure involves mechanical removal of the vitreous humor using a vitreous cutter, excision of the subretinal membrane, and may include intraoperative use of air, gas, or silicone oil to stabilize the retina. Laser photocoagulation can also be applied intraoperatively to repair damaged retinal tissue when indicated.
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Service Type: Surgical ophthalmology procedure — retinal surgery (pars plana vitrectomy with subretinal membrane removal)
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Typical Site of Service: Ambulatory surgical center or hospital operating room
Clinical & Coding Specifications
Clinical Context
A 76-year-old patient with progressive vision loss in the right eye due to neovascular (wet) age-related macular degeneration presents with decreased central vision, metamorphopsia, and a fibrovascular subretinal membrane on clinical exam and optical coherence tomography (OCT). After unsuccessful or incomplete response to intravitreal anti-VEGF therapy and evidence of a contractile subretinal membrane causing persistent hemorrhage and retinal traction, the retinal surgeon schedules a pars plana vitrectomy with subretinal membrane removal (67043). The typical clinical workflow includes preoperative evaluation with OCT, fluorescein angiography as indicated, informed consent, general or monitored anesthesia care, intraoperative core and peripheral vitrectomy using a vitreous cutter, delicate removal of the subretinal membrane, possible endolaser photocoagulation, and intraocular tamponade with air, gas (eg, SF6 or C3F8), or silicone oil if required. Postoperative care includes topical antibiotics and corticosteroids, intraocular pressure monitoring, positioning instructions if gas is used, and follow-up visits with retinal imaging to assess macular anatomy and visual recovery.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Normal, uncomplicated procedure | Use when the procedure was performed under routine circumstances without unusual services. |
| Increased procedural services | Use when substantial additional work beyond typical vitrectomy is documented (complex membrane dissection, prolonged case time).