Billing code 67042: Retinal surgeryMedicare rate & RVUs in Delaware
Reports pars plana vitrectomy with retinal internal limiting membrane removal, most often to repair a macular hole, with tamponade or focal laser when performed.
CMS doesn’t publish an office rate for 67042 in Delaware.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 67042 covers
A retinal surgeon removes vitreous gel through a pars plana approach to reach the retina, then peels the internal limiting membrane when treating a macular hole. The procedure is commonly performed in an operating room or ambulatory surgery setting. Air or gas tamponade and focal endolaser may be part of the service when performed. The code is also used for selected retinal conditions requiring this membrane peel, such as diabetic macular edema.
Report this code when the operative documentation supports vitrectomy and removal of the internal limiting membrane; distinguish it from membrane peeling without ILM removal or vitrectomy without a peel. Document the indication, operative approach, and structures treated. A 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care. For multiple procedures in one session, the highest-valued procedure is paid in full and others at 50%. Bilateral reporting with modifier 50 is paid at 150%. Assistant-at-surgery payment may be available; co-surgeon payment requires supporting documentation, and team surgery is not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
67042 in Delaware
| Payment locality | Office | Facility |
|---|---|---|
| Delaware | Unavailable | $948.41 |
How the 67042 rate is calculated
Each of 67042’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 67042
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 15.92Practice expense 11.39Malpractice 1.27
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 67042
67042 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 67042
Retinal surgery
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 090 | Major surgery: the day before, the day of, and 90 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 1 | Bilateral with modifier 50 pays 150% of the fee schedule amount. |
| Assistant at surgery (80/81/82/AS) | 2 | Paid. |
| Co-surgeons (62) | 1 | Permitted with supporting documentation. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.10/0.70/0.20 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 67042
Retinal surgery
90-day global period ends
Dec 30, 2026
Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).
Visit on Oct 31, 2026
Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.
Pre-op dayGlobal period
What modifiers do to the payment
Modifier 50 · payment effect
With and without the modifier
67042 without 50 · national facility
$954.60
Retinal surgery
67042-50 · Bilateral: 150%
$1,431.90
Both sides on one line with modifier 50 are paid at 150% of the fee schedule amount (subject to multiple-procedure rules with other procedures).
67042 compared with similar codes
Compare codes
67042 vs 67041 vs 67043 vs 67036: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 67041Vitrectomy
- Choose 67041 for vitrectomy with preretinal cellular membrane removal, such as a macular pucker, when the documented work does not include ILM removal.
- 67043Vitrectomy
- Choose 67043 when the surgeon removes both a preretinal cellular membrane and the internal limiting membrane; 67042 represents the ILM peel without that combined membrane removal.
- 67036Vitrectomy
- Choose 67036 for pars plana vitrectomy without the ILM removal represented by 67042.
67042 billing questions
How does this differ from 67041?
67042 represents an internal limiting membrane peel, typically for macular-hole repair. 67041 is for peeling a preretinal cellular membrane, such as a macular pucker, without the ILM removal represented by 67042.
Can air or gas tamponade and focal endolaser be reported separately?
When performed as part of this vitrectomy, air or gas tamponade and focal endolaser are included in the service.
How is bilateral surgery reported?
Use modifier 50 for a bilateral procedure; CMS pays the bilateral service at 150%.
What happens when another procedure is performed in the same session?
Under the standard multiple-procedure reduction, the highest-valued procedure is paid in full and the other procedure or procedures are paid at 50%.
What documentation supports reporting 67042 rather than 67036?
The operative note should document the vitrectomy and removal of the internal limiting membrane. 67036 represents vitrectomy without the ILM-peel work described by 67042.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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