Ophthalmology and Optometry Coding Alert

Question: I have always used 67015 for removal of silicone oil. How does it compare to 67036?

New York Subscriber

Answer: The choice between 67015 (aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach [posterior sclerotomy]) and 67036 (vitrectomy, mechanical, pars plana approach) depends on what the physician did during the surgery. Code 67036 describes three small incisions made in the eyeball, one for a light cannula, one for an infusion cannula, and one for the cutting and suction instrument used to extract the vitreous (posterior sclerotomy). The incisions are repaired with layered closures. Code 67015 describes the insertion of a needle into the posterior chamber through the pars plana to suction vitreous fluid; sometimes a posterior sclerotomy is made to release the fluid. The physician extracts the vitreous with a special instrument by a cutting and suctioning process. In both of these procedures, a physician may use a rotoextractor, or a vitreous infusion suction cutter. Both procedures describe removal of vitreous fluid, which in this case is vitreous substitute (silicone oil). Retina surgeons have used both codes to describe silicone oil removal, although the work described in 67015 more closely matches the silicone oil removal process.

Tip: Check with the physician before coding the claim. He or she may be able to give you additional information not included in the operative report.


Answers to You Be the Coder and Reader Questions were contributed by Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based coding and compliance consulting company; Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and compliance consulting company specializing in ophthalmology; Sherry Searson, CPC, independent coding consultant in Ravenel, S.C.; and Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc., a coding and compliance consulting company based in Spring Lake, N.J.