How To Use CPT Code 67039

CPT 67039 describes a specific procedure performed on the posterior segment of the eye. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 67039?

CPT 67039 is a code that represents a procedure performed on the posterior segment of the eye. This procedure involves the removal of vitreous humor, the semi-liquid substance that fills the space between the lens and the retina. The purpose of this procedure is to gain surgical access to the back of the eye for further treatment or intervention.

2. Official Description

The official description of CPT code 67039 is: ‘Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation.’ This procedure involves the use of a mechanical approach to remove the vitreous humor from the eye, specifically through incisions in the pars plana. Additionally, focal endolaser photocoagulation is performed to treat small localized areas for retinal conditions.

3. Procedure

1. The procedure begins with the patient being appropriately prepped and anesthetized.
2. The provider places a special contact lens on the patient’s cornea to aid in visualization.
3. Using vitrectomy equipment, the provider makes small incisions in the eye to access the posterior segment.
4. The vitreous humor is then removed from the eye through a process known as posterior sclerotomy.
5. In addition to vitrectomy, the provider performs focal endolaser photocoagulation to treat specific retinal conditions.
6. The provider closes the incisions with layered sutures and may apply a pressure patch with antibiotic ointment.

4. Qualifying circumstances

CPT 67039 is performed on patients who require surgical access to the posterior segment of the eye. This procedure is typically indicated for retinal conditions that can be treated through vitrectomy and focal endolaser photocoagulation. The provider must use a mechanical approach through incisions in the pars plana to remove the vitreous humor and perform the necessary treatment.

5. When to use CPT code 67039

CPT code 67039 should be used when a provider performs a vitrectomy using a mechanical approach through incisions in the pars plana, along with focal endolaser photocoagulation. This code is appropriate for cases where the removal of vitreous humor and treatment of retinal conditions are necessary. It is important to ensure that the procedure meets the specific requirements outlined in the official description of CPT code 67039.

6. Documentation requirements

To support a claim for CPT code 67039, the provider must document the following information:

• Patient’s diagnosis and the need for vitrectomy and focal endolaser photocoagulation
• Details of the procedure, including the approach used and the specific retinal conditions treated
• Date of the procedure
• Any additional procedures or interventions performed
• Any complications or adverse events that occurred
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 67039, it is important to ensure that the procedure meets the specific requirements outlined in the official description. The provider should use the appropriate code based on the specific procedure performed. It is also important to follow any additional guidelines or instructions provided by the payer or coding guidelines.

8. Historical information

CPT code 67039 was added to the Current Procedural Terminology system on January 1, 1991. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with diabetic retinopathy undergoes vitrectomy with focal endolaser photocoagulation to treat leaking microaneurysms in the eye.
2. A patient with macular edema undergoes vitrectomy with focal endolaser photocoagulation to address retinal thickening.
3. A patient with a retinal detachment undergoes vitrectomy with focal endolaser photocoagulation to repair the detachment.
4. A patient with a vitreous hemorrhage undergoes vitrectomy with focal endolaser photocoagulation to stop the bleeding and restore vision.
5. A patient with proliferative vitreoretinopathy undergoes vitrectomy with focal endolaser photocoagulation to address the abnormal blood vessels in the eye.
6. A patient with a macular hole undergoes vitrectomy with focal endolaser photocoagulation to close the hole and improve vision.
7. A patient with a vitreous floaters undergoes vitrectomy with focal endolaser photocoagulation to remove the floaters and improve visual clarity.
8. A patient with a retinal tear undergoes vitrectomy with focal endolaser photocoagulation to repair the tear and prevent further complications.
9. A patient with a vitreous abscess undergoes vitrectomy with focal endolaser photocoagulation to treat the infection and preserve vision.