CPT code 67113—repair of complex retinal detachment (RD)—is one of the most nuanced codes in vitreoretinal surgery. Because the code includes multiple procedures and has a designation as a CGS audit target, accurate coding and documentation are more critical than ever.

UNDERSTANDING THE CODE

The indications for CPT code 67113 are: RD and proliferative vitreoretinopathy (PVR), diabetic tractional RD, retinopathy of prematurity, or retinal tears greater than 90°.

The procedure must include both pars plana vitrectomy and membrane peeling; additional procedures may include the following:

  • Air, gas, or silicone oil tamponade
  • Cryotherapy
  • Endolaser photocoagulation
  • Drainage of subretinal fluid
  • Scleral buckling
  • Removal of lens

This bundled code reflects the intensity and complexity of the procedure. It should only be reported when specific diagnoses and the required procedures are medically necessary and performed during the same operative session to repair an RD.

CGS AUDIT

CGS, a Medicare administrative contractor, has flagged CPT code 67113 as a targeted probe and educate (TPE) audit focus for ophthalmology services.1 This means practices must be vigilant in justifying medical necessity, ensuring complete documentation, and avoiding overuse or misapplication.

CGS has a fact sheet that provides insight into the audit expectations, including establishing medical necessity based on RD type, proving a pars plana vitrectomy and membrane peeling are required, using the appropriate modifier(s), and completing compliant signature requirements.2

What to Expect From a TPE

TPE audits can be either a pre- or post-payment audit. If you receive an audit notice, or an additional documentation request, you must respond within 45 days or you will fail the round. Each round examines 20 to 40 claims. After each round, a letter with the results is mailed and may require a review, called a discussion and education. If you fail the first round, you will face a second review. If a physician fails the third round, further action will be taken, including referral to a recovery auditor contractor, extrapolation, or other action.3 Common claim errors include the following:

  • The certifying physician's signature was not included.
  • Encounter notes didn't support all elements of eligibility.
  • Documentation did not meet medical necessity.
  • Initial certifications or recertifications were missing or incomplete.

Bundled Procedures

Due to the complexity of the descriptor, many retina procedures are bundled with CPT code 67113 and should not be unbundled with modifier -59 when performed during the same session and on the same eye. A few examples of these bundles include the following:

  • 67036-67043, family of vitrectomy codes
  • 66850-66852, lens removal
  • 66982-66984, cataract removal with IOL implantation
  • 67028, intravitreal injection

CODING EXAMPLES

Diabetic Tractional RD

A patient with a diabetic tractional RD undergoes vitrectomy with membrane peeling, endolaser, and gas tamponade.

  • Correct code: 67113
  • Modifier: -RT or -LT as appropriate
  • Documentation tip: Clearly indicate the extent of the tractional RD and the procedures performed, and include operative details such as membrane peel and tamponade agent used.

Recurrent RD Post-Vitrectomy

A patient previously treated with CPT code 67108 returns with a recurrent RD and extensive PVR. The surgeon performs vitrectomy, scleral buckle, membrane peel, and silicone oil injection.

  • Current code: 67113
  • Modifier: -58 (staged or related procedure during postoperative period)
  • Documentation tip: Reference the prior surgery, explain the progression to a more complex repair, and include the rationale for each added procedure.

DOCUMENTATION CHECKLIST ESSENTIALS

To support CPT code 67113, your operative report should include the following:

  • Diagnosis: Specify the complexity.
  • Procedure details: Describe each component.
  • Medical necessity: Explain why each step was required.
  • Laterality and modifiers: Use -RT or -LT or modifiers -58, -78, or -79 when applicable.
  • Postoperative plan: Include the follow-up strategy and any staged procedures.

SURVIVE THE AUDIT

With CPT code 67113 under scrutiny, coding accuracy is not just about reimbursement—it’s about audit resilience and clinical integrity. By aligning documentation with payer expectations and surgical complexity, practices can confidently navigate this challenging code.

1. MR activities. CGS. Updated May 21, 2025. Accessed September 19, 2025. tinyurl.com/3eefam2k

2. Fact sheet. CMS. March 31, 2025. Accessed September 19, 2025. www.cgsmedicare.com/partb/mr/pdf/67113.pdf

3. Targeted probe and educate. CMS. Accessed September 19, 2025. tinyurl.com/235tp92k