Ophthalmology - Intravitreal Injections (Lucentis & Eylea)

📋 The Rule (Quick Summary)

Drug vs. Procedure: You bill for the injection (67028) AND the drug (J-Code). Bilateral Rule: Medicare requires bilateral injections to be billed as two separate lines with -RT and -LT (not -50).

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💰 CPT Selection Logic

• 67028: Intravitreal Injection (The poke).
• J-Codes (The Liquid Gold):
  • J0178 (Eylea): Check units carefully (usually 2mg).
  • J2778 (Lucentis): Check units (0.3mg vs 0.5mg).
  • J9035 (Avastin): Off-label use (Low cost).
  • J2779 (Vabysmo): Newer, high audit risk.

⚠️ Modifier Watch

• -25 (E/M): High Denial Risk. Only use if the decision to inject was made that day for a new problem. If it’s a scheduled monthly shot, NO E/M allowed.
• -LT / -RT: Mandatory on the 67028 line.
• -JW: Waste modifier. If the vial was 2.0mg and they injected 1.5mg, you must bill the waste on a separate line with -JW (Commercial policies vary).

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🚨 Documentation Alerts (Query Triggers)

1. “Wasted Amount”: Did the nurse document “0.5mg wasted”? If not, you can’t bill the waste.
2. Diagnosis Linking: Ensure the drug is FDA-approved for the diagnosis (e.g., Eylea for Wet AMD is fine; Eylea for “Eye Pain” will deny).