New vitreoretinal codes represent major change for 2008

In early 2008, major vitrectomy coding changes were made to the eye section of the CPT manual. The former 67038 code was replaced by three new codes: 67041, 67042, and 67043. In addition, a new complex retinal detachment code 67113 was created. The changes reflect the expanding indications and techniques for vitreous surgery that have taken place during the last two decades. Physicians and office staff must become familiar with the new codes in order to receive maximum reimbursement from Medicare and private payers.

A major change in the eye section of the Current Procedural Terminology (CPT) coding manual took place beginning this year, with important implications for physician reimbursement. The "old standby" code, CPT 67038-vitrectomy, mechanical, pars plana approach, with epiretinal membrane stripping-was removed from CPT. It was replaced by three new codes. In addition, a complex retinal detachment repair code was created. Consequently, the nature of reporting of many vitreoretinal procedures has been dramatically altered.

Vitreous surgery has undergone great developments during the past two decades. The indications for vitrectomy have expanded significantly, and techniques have been modified accordingly. Many disparate vitreous cases ended up "lumped" into 67038 when that option was available in the code set.

The vitrectomy code was changed, at least in part, because code 67038 was brought by Centers for Medicare and Medicaid Services to the "5-year review" for consideration of modifying the valuation of that code. The American Medical Association Relative Value System Update Committee determined that it was not possible to arrive at correct valuation with code 67038 as written. Rather, it was recommended that the code be brought to the CPT editorial panel for modification. With the ensuing changes, vitreous surgery once again is described accurately.

The three new codes that evolved from 67038:

The new complex retinal detachment code appears in CPT 2008 as:

The descriptor for the complex retinal detachment code 67113 closely resembles that of CPT 67108. The differences are that the complex retinal detachment code descriptor provides examples of the various scenarios in which 67113 might be indicated, adds membrane peeling, and also includes silicone oil tamponade if utilized. The vignette for 67113 includes a description of a posterior retinotomy. This descriptor is absent from the description of 67108.

The old CPT 67028 carried slightly fewer than 40 total relative value units (RVUs). Valuations of the four new codes range from 30 to 40 RVUs.

Medicare's Correct Coding Initiative bundles the three vitrectomy codes, 67041 through 67043, with 67108, repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique. This is a change from the old 67038, which was payable in addition to 67108. Now, a procedure combining a scleral buckle with pars plana vitrectomy and membrane peeling is reported as 67113 rather than the combination of 67038 and 67108.

As would be expected, code 67108 cannot be billed in addition to 67113, the complex retinal detachment code. Because 67113 lists removal of lens in the descriptor, the cataract extraction codes are bundled into 67113. The three vitrectomy codes (as was the case with the old 67038) may be billed in addition to the cataract extraction codes.