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vitrectomy coding dilemna

  1. Question vitrectomy coding dilemna
    Medical Coding Books
    Our retinal surgeon recently operated on a patient for a dislocated IOL. He listed procedure as Pars plana vitrectomy, intraocular lens removal and intraocular lens suturing to the iris.

    However, the operative report states the following " a 3-port, 23 gauge vitrectomy kit was set up with the infusion cannula placed at the 4 o'clock position......Two other cannulas were placed in the superonasal and superotemporal quadrant 4 mm posterior to the limbus as well. Since the patient has a history of retinal detachment with an epiretinal membrane that was treated with two vitrectomies, there was not much vitreous left, so we proceeded directly by taking hte lens out, this was done using anterior chamber throught he pupillary opening, with one hand, the lens was grasped from the posterior pole and when it reached the pupillary margin, we went through the superotemporal cannula with another forceps abd pushed the lens in the anterior chamber..." My coding gut is telling me that a true vitrectomy was not done...however the Dr. is insisting a 67036 be used in addition to the IOL code 66986. He states he had the vitrector out and used a pars plana approach....he is very convincing....however I am not sure if that is truly the code to use...any input?

  2. #2
    Lexington Kentucky Chapter
    Based on your posting, I would agree with you; sounds more like a 66852 Removal of lens material; pars plana approach, with or without vitrectomy or perhaps more accurately 66825 Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure). While your surgeon takes the pars plana approach, there is no mention of removal of vitreous material, hence no true vitrectomy was performed.

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