CPT Code 67038

CPT code 67038 is a medical procedure code for the surgical removal of a retinal membrane.

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What is CPT Code 67038

CPT code 67038 is a medical procedure code that describes the surgical removal of an epiretinal membrane from the eye. This procedure is typically performed by an ophthalmologist using microsurgical techniques to carefully peel away the thin scar tissue that has formed on the retina. The removal of this membrane can help improve visual acuity and reduce visual distortion caused by the membrane's presence.

Does CPT 67038 Need a Modifier?

For CPT code 67038, which pertains to the surgical procedure of stripping a retinal membrane, several modifiers may be applicable depending on the specific circumstances of the surgery and billing considerations. Here is an ordered list of potential modifiers and the reasons for their use:

1. -LT (Left side) and -RT (Right side): These modifiers are used to specify which eye underwent the procedure, as retinal surgeries are specific to each eye.

2. -50 (Bilateral procedure): If the procedure is performed on both eyes during the same operative session, this modifier should be used to indicate a bilateral procedure.

3. -51 (Multiple procedures): This modifier is used when multiple procedures are performed during the same surgical session. It helps in adjusting the reimbursement for the additional procedures, which are generally paid at a reduced rate.

4. -59 (Distinct procedural service): This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This can be applicable if another significant and separately identifiable procedure was performed on the same eye.

5. -78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period): This modifier is used if a return to the operating room is required to address a complication from the initial surgery.

6. -79 (Unrelated procedure or service by the same physician during the postoperative period): Use this modifier if a new procedure, which is unrelated to the original procedure, is performed during the postoperative period.

7. -24 (Unrelated evaluation and management service by the same physician during a postoperative period): This modifier is applicable if an unrelated evaluation and management service is performed during the postoperative period of the initial procedure.

8. -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service): This can be used if, on the day of the procedure, a significant and separate evaluation and management service is required and performed.

9. -AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery): This modifier is used when these non-physician practitioners assist in the surgery.

Each of these modifiers serves to provide specific information that affects how billing and reimbursement are handled, ensuring that the services rendered are accurately documented and compensated. It's crucial for healthcare providers to use these modifiers correctly to comply with billing regulations and to facilitate appropriate payment from insurers.

CPT Code 67038 Medicare Reimbursement

CPT code 67038, which refers to the surgical procedure for stripping a retinal membrane, is generally reimbursed by Medicare. However, the specific amount of reimbursement can vary based on several factors including the geographic location of the service, the setting in which the procedure is performed (hospital outpatient department vs. ambulatory surgical center), and the Medicare Administrative Contractor (MAC) policies for the region.

To determine the exact reimbursement amount, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) lookup tool available on the Centers for Medicare & Medicaid Services (CMS) website. This tool provides detailed information about the reimbursement rates for specific CPT codes based on the locality. Additionally, checking with the local MAC can provide insights into any specific documentation requirements or coverage limitations related to this procedure.

Are You Being Underpaid for 67038 CPT Code?

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately reading your contracts and identifying underpayments with precision down to specific CPT codes, such as 67038 for stripping retinal membrane procedures. Schedule a demo today to see how RevFind can help ensure that each claim is paid correctly according to your payer agreements. Don't let underpayments go unnoticed—let RevFind safeguard your revenue.

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