Ophthalmology and Optometry Coding Alert

Question: What ICD-10 code should I report for silicon oil removal?

New Mexico Subscriber

Answer: ICD-10 code T85.398A (Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter) is the most common diagnosis code for silicon oil removal, which is usually done to address a complication of retinal repair.

Example: The ophthalmologist examines 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. T85.398A is the best ICD-10 code to describe this patient’s problem.

Procedure: Commonly, an ophthalmologist will perform a vitrectomy in these situations. Report CPT^® 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.

However: If the record does not indicate that the removal of the silicon oil was planned, and the first procedure is greater than the removal of the silicon, use modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) for the related procedure if it was performed during the postoperative period of the first procedure.