Can You Report 67010 Separately From Cataract Surgery?
Question: I have an op note for a complex cataract surgery where the surgeon performed an unplanned vitrectomy due to a posterior tear/vitreous prolapse. Below are highlights from the note: Posterior capsular tear requiring anterior vitrectomy and placement of sulcus 3-piece lens. Apparent there was a posterior capsular tear, previously obscured by epinucleus. Small strand of prolapsed vitreous was present at the temporal incision … was cut. Inferior paracentesis incision was created… presence of some vitreous at the temporal incision. Anterior vitectomy was initiated. Anterior chamber and angle were swept to clear vitreous. Remove vitreous from a posterior location. Lens on a B-cartridge was injected into the ciliary sulcus. Miotic pupil remained circular with no evidence of vitreous prolapse. How should we report the unplanned vitrectomy procedure? Tennessee Subscriber Answer: When the surgeon performs the anterior vitrectomy during the cataract surgery because of the posterior capsule rupture and vitreous prolapse, the vitrectomy is considered part of the cataract procedure. The capsule rupture and vitreous prolapse are recognized complications of cataract surgery. The vitrectomy is performed to manage the complication and support intraocular lens (IOL) placement; therefore, you’ll report 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation) to report the complex cataract surgery. On the other hand, you can report 67010 (Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy) separately with modifier 59 (Distinct procedural service) when the anterior vitrectomy is preplanned and medically necessary, unrelated to the cataract surgery, and the documentation shows the intent, indication, and anatomical service. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
