Ophthalmology and Optometry Coding Alert

Question: What is the proper code for removal of a scleral buckle? And what is the proper diagnosis code for extrusion of a scleral buckle and an infected scleral buckle?

Eileen Rymdeika, Office Manager
Retina Associates of Greater Philadelphia
N. Wales, Pa.

Answer: The proper procedure code for removal of the buckle is 67120 (removal of implanted material, posterior segment; extraocular). A buckle is used after a retinal tear has been treated by a burn, which seals the choroid to the retina. The scar, which is healing tissue, is supported by a band that entirely encircles the eye and is called the scleral buckle.

In some cases, the scleral buckle is protruding and bothers the patient. If there is enough scar tissue, that alone would hold the tear. Sometimes, an infection has caused the buckle to extrude. For the diagnosis code, there are some options. You could use a nonspecific diagnosis code and submit an operative report with a paper claim describing what was done, and why the buckle had to be removed.

For example, you could use 361.00 (retinal detachment with retinal defect, unspecified), or 361.02 (recent detachment, partial, with multiple defects). But you should always use one of the retinal detachment codes, since that is the condition that caused the buckle to be placed. You also should use one of the complications diagnosis codes, such as 996.59 (complications peculiar to certain specified procedures; due to other implant and internal device, not elsewhere classified).

Another code that applies is 996.69 (infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to other internal prosthetic device, implant, and graft). There is no specific diagnosis code for removal of a scleral buckle. When choosing the diagnosis codes, look at the primary reason why the procedure is being done as the primary diagnosis.

You should code the underlying problem that is causing the extrusion of the buckle (i.e., 996.59 or 996.69) as the primary diagnosis and the reason the buckle was originally placed as a secondary diagnosis (i.e., 361.00 or 361.02).