There is ongoing confusion regarding how to correctly code the removal of silicone oil. Silicone oil is used in cases of a chronic retinal detachment, proliferative vitreoretinopathy (PVR; scarring), advanced cases of diabetic retinopathy, macular holes, and other disease processes that require long-term tamponade of the retina following vitrectomy. It is injected into the eye following vitrectomy and left in the eye until the surgeon determines the retina is stable.

Removing silicone oil following a complex retinal detachment typically occurs via either vitrectomy or aspiration without a vitrectomy. The two most common codes used for removal of oil, without treatment of other pathology, are 67036 and 67121. The Current Procedural Terminology (CPT) manual defines these two codes as:

• 67036 – Vitrectomy, mechanical, pars plana approach
• 67121 – Removal of implanted material, posterior segment; intraocular

When removing the oil is the only procedure completed, the coding is easily determined by examining the technique described by the surgeon in the operative report. If a pars plana vitrectomy (PPV) is used, CPT code 67036 is used; if a vitrector is not used and the oil is removed with aspiration, consider 67121. However, patients are often more complicated and the answers can vary with respect to CPT, diagnosis coding, and modifiers. Consider the rationale and timing for oil removal, and ask the following questions:

• Is oil removal a second stage of the primary procedure?
• Is oil removal necessitated by a new problem?
• Did the oil cause a complication for which removal is the solution?
• Is there a secondary problem (comorbidity)? If yes, is it complicated by the oil?
• Is the oil being removed in the global period of the retinal detachment repair?

The following examples will shed some light on the best ICD-10 code(s) and the need for any modifiers.

EXAMPLE 1: STAGED PROCEDURE

Surgeons often plan to remove the oil as the eye approaches stability. However, stability is not fully reached until the final staged procedure — removal of silicone oil — is performed. From the patient’s perspective, the presence of silicone oil causes poor vision. Therefore, the appropriate diagnosis code for the procedure to remove the oil is the original diagnosis from the primary procedure. Conflict and misunderstandings arise when chart notes state “retina stable” or “retina flat,” as if a satisfactory endpoint has been reached. The retina appears flat with an imperfect view through the oil when, in fact, the treatment of the primary problem is neither complete nor successful until the oil is removed.

If the oil removal transpires during the postoperative period, append modifier -58 (staged procedure) to the procedure code; outside of the global period, the concept of a staged procedure still applies but the modifier is unnecessary. The appropriate CPT codes are likely 67036 or 67121.

EXAMPLE 2: NEW CONDITION

A patient returns 4 months after vitrectomy of the right eye with placement of silicone oil having developed a new epiretinal membrane (ERM). The surgeon recommends vitrectomy with ERM stripping as well as removal of silicone oil. The ICD-10 code, H35.371 (puckering of macula, right eye), is used on the claim. The silicone oil is removed during the vitrectomy/membrane peel, which is reported as CPT 67041 (PPV with removal of preretinal cellular membrane), so no separate charge is made for removal of the oil.

If the ERM stripping occurred during the 90-day global period, modifier -79 would apply because the procedure and condition are unrelated to reason for the initial procedure, and the ERM development might have occurred regardless of the oil.

EXAMPLE 3: RECURRENT CONDITION

The patient had a retinal detachment with PVR. The surgeon performed a vitrectomy with membrane stripping with injection of silicone oil (CPT 67113). The patient recovered nicely following surgery, although the oil remained in the eye. Now, the patient presents with a recurrent retinal detachment and PVR 4 months after surgery. The surgeon recommends another vitrectomy with membrane stripping.

Use the appropriate retinal detachment ICD-10 code (H33.-) along with CPT 67113. No additional charge is made for the removal of the oil. If the recurrent retinal detachment develops during the 90-day global period, modifier -78 applies because the procedure and condition are related and the coding for the initial procedure was 67113.

EXAMPLE 4: COMPLICATION

The patient develops a complication from the presence of the silicone oil, such as an IOP spike not controlled with medical therapy, so the oil needs to be removed. Although it may be tempting to use the same diagnosis as the primary procedure as described in example 1, the reason for removing the oil is the subsequent elevated IOP secondary to appropriate use of the silicone oil, not the aforementioned retinal problem.

According to ICD-10, an ocular surgical complication from an implant is coded as T85.398- (other mechanical complications of other ocular prosthetic devices, implants and grafts). Pertinent secondary ICD-10 codes would apply as well. If the complication develops during the 90-day global period, modifier -78 applies because the procedure and condition are related.

FINAL THOUGHTS

If only oil is being removed, the CPT coding is obvious. However, when considering other factors such as global periods, complications, recurrence, comorbidities, and/or new problems, the answers become complicated. Consider the questions above in order to reach the correct answer. RP