Ophthalmology and Optometry Coding Alert

Question: If 67025 and 67038 are performed on the same day, what is the proper modifier to use?

Texas Subscriber


Answer: Codes 67025 (injection of vitreous substitute, pars plana or limbal approach, [fluid-gas exchange], with or without aspiration [separate procedure]) and 67038 (vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping) are bundled by the Correct Coding Initiative (CCI); 67025 is bundled with 67038 as a more comprehensive bundle.

You may not bill Medicare for both if performed on the same eye in the same session. If performed on different eyes, use the -59 modifier (distinct procedural service) on the second line item and -RT (right side) and -LT (left side) modifiers to indicate which eye was involved for each procedure. If performed at different sessions, but on the same day on the same eye, append modifier -59 to 67025. Although Medicare will not pay, if you bill a different insurance company, it may not be using the CCI edits and may pay.