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?
Assign CPT code 67042, Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil).
Although CPT codes 67042 and 67039, Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation, together capture both the internal limiting membrane removal and endolaser treatment of the macroaneurysm, the NCCI edit prevents both codes from being reported as they are considered mutually exclusive. In this case, CPT code 67042 is assigned as it is considered the more extensive procedure.
In addition, assign the HCPCS Level II J code that accurately describes the specific tPA administered (HPCS Level II codes J2993-J2997, J3101, J3364-J3365 or J3490 if there is no HCPCS Level II code that accurately captures the specific name of the tPA utilized).
It is not appropriate to report HCPCS Level II code C9770, Vitrectomy, mechanical, pars plana approach, with subretinal injection of pharmacologic/biologic agent, for the administration of the tPA. HCPCS code C9770 describes the administration of subretinal therapies requiring vitrectomy, however in this case the vitrectomy is accurately described by CPT code 67042.