How To Use CPT Code 67041

CPT 67041 describes a surgical procedure known as vitrectomy with removal of preretinal cellular membrane. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 67041?

CPT 67041 is a code used to describe a surgical procedure called vitrectomy with removal of preretinal cellular membrane. This procedure involves the removal of scar tissue from the retinal membrane to improve vision. The provider uses a mechanical cutting tool to remove the vitreous humor, the gelatinous material that gives shape to the eye, in order to access the scar tissue.

2. Official Description

The official description of CPT code 67041 is: ‘Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker).’ This code specifically refers to the surgical excision of scar tissue from the retinal membrane using a mechanical cutting tool.

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made through the pars plana, a structure in the middle of the eye.
3. A mechanical cutting tool is inserted through the incision to remove the vitreous humor from the eye.
4. The provider uses intraocular micro forceps to lift the edges of the cellular membrane and gently peels it away, removing the scar tissue.
5. The incision is closed with sutures, intraocular pressure is restored, and a topical antibiotic is applied to the eye.
6. An eye pressure patch may be applied to protect the eye during the healing process.

4. Qualifying circumstances

CPT 67041 is performed on patients with a thin layer of scar tissue on the eye’s macula, also known as a preretinal cellular membrane or macular pucker. This condition distorts the retina and impairs vision. The procedure is typically performed by a qualified healthcare professional who specializes in ophthalmology or vitreoretinal surgery.

5. When to use CPT code 67041

CPT code 67041 should be used when a vitrectomy is performed with the specific purpose of removing a preretinal cellular membrane. It is important to note that this code is not appropriate for other vitrectomy procedures that do not involve the removal of scar tissue from the retinal membrane.

6. Documentation requirements

To support a claim for CPT 67041, the healthcare professional must document the following information:

• Patient’s diagnosis of a preretinal cellular membrane
• Description of the procedure performed, including the use of a mechanical cutting tool
• Date of the procedure
• Details of the incision and closure
• Any additional procedures or interventions performed during the same session
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 67041, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the removal of the preretinal cellular membrane and the use of a mechanical cutting tool. Additionally, be aware of any specific guidelines or requirements set by the payer regarding the reporting of this code.

8. Historical information

CPT 67041 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes vitrectomy with removal of preretinal cellular membrane to improve vision affected by macular pucker.
2. A provider performs vitrectomy with removal of preretinal cellular membrane on a patient with cellophane retinopathy.
3. A vitreoretinal surgeon uses CPT code 67041 to bill for the removal of a preretinal cellular membrane during a vitrectomy procedure.
4. A patient with internal limiting membrane disease undergoes vitrectomy with removal of preretinal cellular membrane to restore visual clarity.
5. A provider performs vitrectomy with removal of preretinal cellular membrane on a patient with a macular pucker to alleviate distortion in the retinal membrane.
6. A qualified healthcare professional uses CPT code 67041 to bill for the surgical removal of a preretinal cellular membrane that impairs a patient’s vision.
7. A patient with epiretinal membrane undergoes vitrectomy with removal of preretinal cellular membrane to improve visual acuity.
8. A provider performs vitrectomy with removal of preretinal cellular membrane on a patient with a macular pucker to alleviate visual distortion.
9. A vitreoretinal surgeon uses CPT code 67041 to bill for the removal of a preretinal cellular membrane during a vitrectomy procedure.
10. A patient with cellophane retinopathy undergoes vitrectomy with removal of preretinal cellular membrane to restore visual clarity.