Ophthalmology and Optometry Coding Alert

Question:  Our ophthalmologist examined a patient who had recently had retinal repair and had silicon oil inserted in the vitreous cavity. The ophthalmologist found elevated pressure in the patient's eye and removed the silicon oil to correct the problem. I can't find a code for the silicon oil removal.Illinois SubscriberAnswer: If your ophthalmologist removed the silicon oil by performing a vitrectomy, which is how it's typically done, report code 67036 (Vitrectomy, mechanical, pars plana approach). Depending on the circumstances and documentation, you may need to use modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) if the removal procedure was planned at the time of the initial vitrectomy procedure in which the silicon oil was inserted. Also, depending on the first procedure performed, the vitrectomy will probably represent a greater procedure following a lesser procedure, which also justifies the use of modifier 58. [...]