AHA Coding Clinic® for HCPCS - 2021 Issue 3; Ask the Editor

Internal membrane peeling with endolaser and subretinal injection

A patient presented with a submacular and sub-internal limiting membrane hemorrhage and vitreous hemorrhage from a macroaneurysm in the left eye. Three trocar cannulas were inserted in the inferotemporal, superotemporal and superonasal positions. An infusion cannula was inserted into the inferotemporal cannula. A core vitrectomy was performed and forceps were used to peel part of the internal limiting membrane off the macula. This released some of the sub-internal limiting hemorrhage. Next, an endolaser was used to treat the macroaneurysm in the macula. Tissue plasminogen activator (tPA) was injected through a small retinotomy to create a bleb under the entire macula. It appears that CPT code 67039 would be assigned to capture the vitrectomy with endolaser and code 67042 would be assigned to capture the vitrectomy with the removal of the internal limiting membrane. However, there is an edit that prevents both of these vitrectomy codes from being reported together and a modifier is not allowed as the procedures are considered mutually exclusive. What are the correct codes to capture all of the components of this procedure? In addition, is it appropriate to assign HCPCS Level II code C9770 to capture the tPA injection? ...

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