Summary & Overview
CPT 67113: Complex Retinal Reattachment Surgery
CPT code 67113 represents complex surgical repair of a detached retina involving vitrectomy, membrane peeling, retinopexy (laser or cryotherapy), possible scleral buckle placement, subretinal fluid drainage, lens removal when necessary, and intraocular tamponade. This procedure is a critical ophthalmic intervention to restore retinal apposition and preserve vision in patients with complicated retinal detachment. Nationally, such interventions carry significant clinical urgency, resource use, and cost implications due to operating-room time, specialty surgeon involvement, and potential need for postoperative care.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a concise policy and billing context for payers and revenue leaders across the U.S. health system.
Readers will gain: a clear clinical and coding description of CPT code 67113; typical site-of-service and service-line placement; common billing considerations and benchmarks where available; and the clinical context that drives utilization and payer interactions for complex retinal reattachment procedures. Data not available in the input will be noted as such in relevant sections.
Billing Code Overview
CPT code 67113 describes surgical repair of a complicated detached retina. The procedure includes removal of the vitreous humor, peeling of epiretinal membranes, and reattachment of the retina using extreme heat (laser photocoagulation) or cold (cryopexy). The surgeon may place a scleral buckle to manage fluid dynamics behind the retina, drain subretinal fluid, remove the lens if required, and inject a substance (e.g., intraocular tamponade) to reapproximate the detached retina.
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Service type: Posterior segment retinal surgery, complex retinal reattachment
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Typical site of service: Hospital operating room or ambulatory surgical center for ophthalmic specialty procedures
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient presents with progressive vision loss and flashes/floaters in the affected eye. Ophthalmic examination and dilated fundoscopy confirm a rhegmatogenous retinal detachment with proliferative vitreoretinopathy (PVR) and extensive subretinal fluid. The patient is scheduled for a primary complex retinal reattachment procedure under regional or general anesthesia.
Preoperative workflow includes informed consent, ocular imaging (optical coherence tomography, B-scan ultrasonography if view is limited), biometry if lens removal is anticipated, and medical clearance. In the operating room, the vitreoretinal surgeon performs a pars plana vitrectomy with removal of vitreous gel, membrane peeling of epiretinal or subretinal membranes, and retinopexy using cryotherapy and/or endolaser. A scleral buckle may be placed to support the retinal break(s) and subretinal fluid may be drained. If required for access or lens opacities, the surgeon performs a lensectomy or phacoemulsification with or without intraocular lens placement. Intraocular tamponade (gas or silicone oil) may be instilled to reapproximate the retina postoperatively. Postoperative care includes positioning instructions, topical antibiotics and steroids, intraocular pressure monitoring, and early follow-up to assess attachment and identify complications such as elevated IOP, infection, or recurrent detachment.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure |