Coding for removal of silicon oil in a retinal surgery


Bloomington, Illinois
Best answers
Good morning. May we ask your assistance?

We have found to have an issue with silicone oil removal and vitrectomy coding mainly due to retinal detachments and proper billing and reimbursement for both physician and facility.

We have researched the proper billing of these cases and have attached documentation of findings which indicated that if the removal was done through Pars Plana Vitrectomy, the proper CPT code would be 67036 and to only bill 67121 if oil removed by aspiration alone.
Our facility has billed Medicare and Medicare Managed Care plans for 67036 with the diagnoses T85.398_ and Z98.890 and received denials of coverage referencing remark code 50, “not deemed a medical necessity”, M64 “missing /incomplete/invalid other diagnosis, and N386 “decision based on NCD”. When Medicare was questioned regarding this denial the representative stated that the diagnoses are not listed for the applicable NCD which is 80.11 Vitrectomy. In reviewing this NCD, the only diagnosis I see listed that might be applicable is H44.751 or H44.752 (retained nonmagnetic foreign body in vitreous cavity (right H44.751 or left H44.752). Would this be acceptable coding to bill CPT 67036 with the H code as first diagnosis and Z98.890 as second diagnosis?
Both the office/facility are receiving payment for 67036 as long as we include the H code from a previous surgery (i.e., retinal detachment), which in our mind is why the silicone oil was injected and needs to be removed, but ultimately, we are worried insurance is paying based solely on that diagnosis, thinking the patient currently has a detachment.
We are currently holding a few patient billing for oil removal and do not wish to submit until we feel it can be billed correctly.

Thank you so much in advance for any assistance you can provide for this issue.