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2025 CPT code 67039

Vitrectomy with focal endolaser photocoagulation.

Refer to the latest CPT manual and other relevant coding guidelines for specific instructions and examples of proper coding for vitreous procedures and endolaser photocoagulation.

Modifiers may be applicable. Common modifiers include -LT (left eye), -RT (right eye), and -50 (bilateral procedure) if the treatment is performed on both eyes. Other modifiers, such as those indicating increased procedural services (22) or reduced services (52), may also be relevant depending on the circumstances. Modifier -59 is crucial to differentiate between distinctly separate procedures performed during the same session.

Medical necessity must be supported by documentation that shows the procedure was necessary to treat a specific retinal condition. Documentation should link the diagnosis, the chosen treatment, and the expected improvement in the patient's visual function or overall eye health.

The ophthalmologist is responsible for performing the procedure, including pre-operative assessment, surgical technique, and post-operative care. They must select the appropriate laser parameters and ensure the patient's safety during and after the surgery.

In simple words: The eye surgeon removes the jelly-like substance from the inside of your eye to reach the back part. They use a laser to treat small areas of your retina.

Pars plana vitrectomy performed with focal endolaser photocoagulation. This involves removing the vitreous gel from the eye through incisions in the pars plana and applying targeted laser treatment to specific areas of the retina.

Example 1: A patient with diabetic retinopathy and localized macular edema undergoes a pars plana vitrectomy with focal laser treatment to the affected areas., A patient with a macular hole undergoes vitrectomy with focal laser to seal the hole., A patient with epiretinal membrane undergoes vitrectomy with focal laser treatment to address retinal complications.

Documentation should include a detailed operative report describing the vitrectomy technique, the location and extent of laser photocoagulation, and any other procedures performed. Pre- and post-operative diagnoses, any complications encountered, and the patient's response to treatment should also be documented.

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