67028

💉CPT 67028 - Intravitreal Injection of a Pharmacologic Agent (Separate Procedure)

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📋 Code Description

Full Official Description: Intravitreal injection of a pharmacologic agent (separate procedure)

CPT 67028 describes the injection of a pharmacologic agent directly into the vitreous cavity of the eye via a transconjunctival, transscleral needle puncture through the pars plana. This is one of the highest-volume surgical procedures performed in the United States, driven primarily by the widespread adoption of anti-VEGF therapy for neovascular (wet) age-related macular degeneration (AMD),diabetic macular edema (DME), and retinal vein occlusion (RVO).

The procedure involves:

• Topical and/or subconjunctival anesthetic application to the conjunctiva and sclera
• Povidone-iodine (Betadine) preparation of the conjunctival fornices and periocular skin — a critical infection-prevention step specifically required by most payer policies for intravitreal injection
• Lid speculum placement for exposure
• Measurement and marking of the injection site — typically 3.5-4.0 mm posterior to the limbus in phakic eyes, or 3.0-3.5 mm in pseudophakic eyes, targeting the pars plana to avoid the lens anteriorly and the retina posteriorly
• Needle insertion (typically a 30-gauge needle on a 1 mL syringe) through the sclera at the marked site, directing toward the center of the vitreous cavity
• Injection of the pharmacologic agent into the mid-vitreous — volumes typically 0.05 mL (50 µL) for most anti-VEGF agents
• Needle withdrawal and gentle digital or cotton-tip pressure at the injection site
• Intraocular pressure (IOP) check post-injection to confirm no acute pressure elevation compromising central retinal artery perfusion
• Indirect ophthalmoscopy or slit-lamp examination to confirm central retinal artery perfusion (light perception check or optic nerve visualization)
• Post-procedure topical antibiotic (practice varies; some retina specialists omit per evidence)

Parenthetical Note: The descriptor includes the phrase “separate procedure” — a CPT designation indicating that 67028 is commonly performed as a component of a more comprehensive service, but may be reported independently when performed as a standalone procedure or when not bundled into a more extensive service on the same date.

⚠️ Drug Billing Note: The pharmacologic agent itself (e.g., bevacizumab, ranibizumab, aflibercept, faricimab) is NOT included in 67028. The drug is billed separately using the appropriate HCPCS J-code or C-code (for hospital outpatient). The CPT code 67028 covers only the professional service of the injection procedure.

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💊 Commonly Injected Agents & Billing Codes

Drug (Brand Name)	Generic Name	HCPCS Code	Route	Primary Use
Eylea	Aflibercept 2 mg	J0178	Intravitreal	Wet AMD, DME, RVO, DR
Eylea HD	Aflibercept 8 mg	J0180	Intravitreal	Wet AMD (high-dose)
Lucentis	Ranibizumab	J2778	Intravitreal	Wet AMD, DME, RVO, DR
Vabysmo	Faricimab-svoa	J0171	Intravitreal	Wet AMD, DME
Avastin	Bevacizumab (compounded)	J9035 / C9257	Intravitreal (off-label)	Wet AMD, DME, RVO
Beovu	Brolucizumab	J0179	Intravitreal	Wet AMD
Susvimo	Ranibizumab (port delivery)	—	Implant (see 67027)	Wet AMD
Ozurdex	Dexamethasone intravitreal implant	J7312	Intravitreal	DME, RVO, Uveitis
Iluvien	Fluocinolone acetonide implant	J7313	Intravitreal	Chronic DME
Yutiq	Fluocinolone acetonide insert	J7314	Intravitreal	Non-infectious posterior uveitis
Triesence / Trivaris	Triamcinolone acetonide	J3301	Intravitreal	Uveitis, DME (off-label)
Jetrea	Ocriplasmin	J2243	Intravitreal	Symptomatic vitreomacular adhesion
Macugen	Pegaptanib sodium	J2503	Intravitreal	Wet AMD (largely obsolete)

💡 Billing Pearl: For bevacizumab (Avastin), which is used off-label for intravitreal injection, billing varies by payer. Many retina practices use C9257 (for HOPDs) or J9035 in an office setting. Compounded bevacizumab requires specific NDC documentation. Medicare covers it when billed correctly, but ABN considerations may apply depending on the indication.

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💰 Work RVUs & Payment

Component	Value
wRVU (Facility)	0.74
wRVU (Non-Facility)	1.63
Global Period	000 (zero days)
Assistant Payable	❌ No (indicator: 0)
Co-Surgery	❌ No
Team Surgery	❌ No
Bilateral Same Day	✅ Reportable — see bilateral section
Multiple Procedure Indicator	2 (standard reduction applies)
Drug Billed Separately	✅ Yes — HCPCS J-code required
Separate Procedure Designation	✅ Yes — per descriptor

0-Day Global Period: 67028 carries a zero-day global period, meaning there is no bundled postoperative care period. The treating physician may bill separately for follow-up visits on the same day or subsequent days without global-period modifier restrictions. This reflects the high-frequency, serial nature of intravitreal injection therapy — many patients receive monthly or bimonthly injections indefinitely, each reported independently.

wRVU Differential: The non-facility wRVU (1.63) is more than double the facility wRVU (0.74). This reflects the additional practice expense borne by the physician when performing injections in an office-based setting (purchasing supplies, maintaining sterile technique equipment, staff time). When performed in an ASC or hospital outpatient department (HOPD), the facility wRVU (0.74) applies to the professional component, and the facility bills separately for the technical component and the drug.

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👁️ Laterality — Critical Billing Requirement

⚠️ Eye Modifiers Are MANDATORY for 67028. Medicare and virtually all commercial payers require a laterality modifier on every claim for 67028. Failure to append a laterality modifier is a top cause of claim rejection and audit vulnerability for retina practices.

Modifier	Description	Usage
-RT	Right eye	Injection performed in the right eye
-LT	Left eye	Injection performed in the left eye
-50	Bilateral procedure	Same-day bilateral injections; some payers prefer two line items with RT and LT
-E1	Upper left eyelid	Not applicable to intravitreal
-E2	Lower left eyelid	Not applicable to intravitreal
-E3	Upper right eyelid	Not applicable to intravitreal
-E4	Lower right eyelid	Not applicable to intravitreal

Bilateral Same-Day Injection Billing

When both eyes receive intravitreal injections on the same date of service (which is clinically common in bilateral wet AMD or bilateral DME), billing options vary by payer:

• Medicare: Report 67028-RT on one line AND 67028-LT on a second line (two separate line items). Medicare does not prefer modifier -50 for eye codes and may process them differently.
• Most Commercial Payers: Two separate line items (RT and LT) or a single line with modifier -50; verify individual payer preference.
• Drug: Each eye’s drug is billed separately with the appropriate J-code, also with -RT/-LT laterality modifiers.
• Payment for Bilateral: The second eye typically receives a 50% reduction on the professional fee when billed on the same day under multiple procedure rules.

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✅ What’s Included (Bundled into 67028)

• Topical and subconjunctival anesthetic administration
• Povidone-iodine conjunctival preparation
• Eyelid speculum placement and removal
• Injection site measurement and marking
• Scleral needle puncture and intravitreal drug delivery
• Post-injection IOP check (digital or tonometry)
• Central retinal artery perfusion confirmation (indirect ophthalmoscopy or slit lamp)
• Application of topical antibiotic (when performed at same session, no separate billing)
• Routine intraoperative patient monitoring
• Standard postoperative instructions and documentation
• Same-day evaluation and management visit bundled unless a separately identifiable, significant, and separately documented E/M service is provided (see modifier 25 section below)

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🚫 Excludes / Separately Reportable

Service	Separately Reportable Code	Notes
The pharmacologic agent (drug) itself	Appropriate HCPCS J-code (J0178, J2778, J7312, etc.)	Always separately reported; drug is not included in 67028
Implantation of intravitreal drug delivery system (e.g., port delivery system)	67027	Port delivery implant; different from injection
Vitreous substitute injection (fluid-gas exchange)	67025	Different agent/purpose; vitreous tamponade
Diagnostic imaging — OCT of macula	92134	Optical coherence tomography; separately reportable with documentation
Diagnostic imaging — fundus photography	92250	Separately reportable with documentation
Fluorescein angiography	92235	Separately reportable; requires documentation
Indocyanine green angiography	92240	Separately reportable
Extended ophthalmoscopy with retinal drawing	92225, 92226	Separately reportable when indicated
E/M visit (same day, separately identifiable)	99202-99215 + 25	Must be significant and separately identifiable beyond routine injection monitoring; requires separate documentation
Subconjunctival injection (separate drug)	67510	If a separate subconjunctival injection of a different agent is performed
Retrobulbar injection	67500	Retrobulbar, not intravitreal; different anatomic location
Anterior chamber paracentesis	65800	If AC tap performed to reduce IOP prior to injection (e.g., in single-eye patient); append 59
Conjunctival incision / peritomy (if required)	68020	Rarely needed for intravitreal injection
Intraoperative complications requiring additional procedures	Appropriate surgical code + 78	Within global (0-day; rarely applicable)

🔴 Modifier 25 — Same-Day E/M with 67028: A High-Audit Area

This is one of the most scrutinized billing scenarios in retina practice and a top OIG audit target.

When modifier 25 IS appropriate:

• Patient presents for scheduled injection AND reports a new symptom (e.g., new floaters, photopsia, vision change beyond expected)
• Physician performs a medically necessary evaluation beyond the routine pre-injection assessment, documents a separate chief complaint, relevant history, examination elements, and separate medical decision-making
• The E/M service results in a separate clinical decision — e.g., discovery of a retinal tear requiring different management, change in treatment plan

When modifier 25 is NOT appropriate:

• Routine monitoring of injection response (visual acuity, IOP check) immediately preceding the scheduled injection
• OCT review that was always part of the injection decision (these are separately billable imaging codes, not E/M)
• Brief pre-injection assessment confirming the eye is ready for injection
• Documentation that mirrors the injection note with minor additions

✅ Best Practice: The E/M note and the procedure note should be clearly distinct documents (or clearly distinct sections of the same document). The E/M must stand on its own merits regardless of the injection. Payers increasingly use AI-driven audit tools to flag 67028 + E/M claims on the same date — ensure documentation is bulletproof.

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🌿 Code Tree / Family

Eye and Ocular Adnexa - Posterior Segment - Vitreous (67005-67043)
│
├── [[67005]]  Removal of vitreous, anterior approach (open sky technique
│              or limbal incision); partial removal
│
├── [[67010]]  Removal of vitreous, anterior approach; subtotal removal
│              with mechanical vitrectomy
│
├── [[67015]]  Aspiration or release of vitreous, subretinal or choroidal
│              fluid, pars plana approach (posterior sclerotomy)
│
├── [[67025]]  Injection of vitreous substitute, pars plana or limbal
│              approach (fluid-gas exchange), with or without aspiration
│              (separate procedure)
│              └── For vitreous substitute (gas, silicone oil); NOT for
│                  pharmacologic agents
│
├── [[67027]]  Implantation of intravitreal drug delivery system
│              (e.g., ganciclovir implant), includes concomitant
│              vitrectomy when performed
│              └── For sustained-release implant devices (Iluvien,
│                  Yutiq, Susvimo port delivery system)
│
├── [[67028]]  ◀ YOU ARE HERE
│              Intravitreal injection of a pharmacologic agent
│              (separate procedure)
│              └── For liquid pharmacologic agents injected directly
│                  into vitreous (anti-VEGF, steroids, antibiotics)
│              ├── [[RT]] - Right eye
│              ├── [[LT]] - Left eye
│              └── Drug billed separately via J-code
│
├── [[67036]]  Vitrectomy, mechanical, pars plana approach
│
├── [[67039]]  Vitrectomy, mechanical, pars plana approach; with focal
│              endolaser photocoagulation
│
├── [[67040]]  Vitrectomy, mechanical, pars plana approach; with
│              endolaser panretinal photocoagulation
│
├── [[67041]]  Vitrectomy, mechanical, pars plana approach; with removal
│              of preretinal cellular membrane (e.g., macular pucker)
│
├── [[67042]]  Vitrectomy, mechanical, pars plana approach; with removal
│              of internal limiting membrane of retina
│
└── [[67043]]  Vitrectomy, mechanical, pars plana approach; with removal
               of subretinal membrane (e.g., choroidal neovascularization)

📌 Injection vs. Implant — Key Code Distinction

Feature	67028	67027
Type	Liquid injection (single dose)	Sustained-release implant device
Frequency	Repeated (monthly/bimonthly/PRN)	Infrequent (implant lasts months-years)
Examples	Anti-VEGF, steroids, antibiotics	Iluvien, Yutiq, ganciclovir implant, Susvimo
Vitrectomy Included?	❌ No	✅ Yes (when performed)
wRVU	0.74 (facility)	Higher — more complex
Global Period	000	090

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🏥 ICD-10-CM Commonly Paired Diagnoses

🔴 Age-Related Macular Degeneration (AMD)

ICD-10-CM	Description	HCC	Notes
H35.31-	Nonexudative age-related macular degeneration, unspecified eye	❌ No HCC	Dry AMD — anti-VEGF rarely indicated; may use for clinical documentation
H35.311-	Nonexudative AMD, right eye	❌ No HCC	Dry AMD, right
H35.312-	Nonexudative AMD, left eye	❌ No HCC	Dry AMD, left
H35.3110	Nonexudative AMD, right eye, stage unspecified	❌ No HCC	Use most specific stage when documented
H35.3190	Nonexudative AMD, right eye, stage unspecified	❌ No HCC	—
H35.32-	Exudative age-related macular degeneration, unspecified eye	❌ No HCC	Wet AMD — primary indication for anti-VEGF
H35.321-	Exudative AMD, right eye	❌ No HCC	✅ Most common diagnosis paired with 67028-RT
H35.322-	Exudative AMD, left eye	❌ No HCC	✅ Most common diagnosis paired with 67028-LT
H35.3211	Exudative AMD, right eye, with active choroidal neovascularization	❌ No HCC	More specific; documents CNV activity
H35.3221	Exudative AMD, left eye, with active choroidal neovascularization	❌ No HCC	More specific; documents CNV activity

💡 ICD-10 AMD Coding Tip: The AMD codes expanded significantly in recent updates to include stage and laterality specificity. Always code to the highest level of specificity documented in the retina specialist’s note. “Wet AMD with active CNV” = H35.3211/H35.3221. Many EHR systems default to unspecified — review the note carefully.

🔴 Diabetic Retinopathy & Macular Edema

💡 Critical Rule: For diabetic eye disease, ICD-10-CM requires combination codes that capture both the type of diabetes AND the ophthalmic manifestation in a single code. Do NOT separately code the diabetes (E11.9) and the retinopathy (H36.0); use the appropriate combination code.

ICD-10-CM	Description	HCC	Notes
E11.311	Type 2 DM with unspecified diabetic retinopathy with macular edema	✅ HCC 18	Common; use when retinopathy type not specified
E11.3211	Type 2 DM with mild nonproliferative DR, right eye, with macular edema	✅ HCC 18	Laterality + stage specific
E11.3212	Type 2 DM with mild nonproliferative DR, left eye, with macular edema	✅ HCC 18	Laterality + stage specific
E11.3311	Type 2 DM with moderate nonproliferative DR, right eye, with macular edema	✅ HCC 18	Very common in DME patients
E11.3312	Type 2 DM with moderate nonproliferative DR, left eye, with macular edema	✅ HCC 18	Very common in DME patients
E11.3411	Type 2 DM with severe nonproliferative DR, right eye, with macular edema	✅ HCC 18	High-risk DR with DME
E11.3412	Type 2 DM with severe nonproliferative DR, left eye, with macular edema	✅ HCC 18	High-risk DR with DME
E11.3511	Type 2 DM with proliferative DR, right eye, with macular edema	✅ HCC 18	PDR + DME — also consider 67228 (PRP laser)
E11.3512	Type 2 DM with proliferative DR, left eye, with macular edema	✅ HCC 18	PDR + DME — also consider 67228
E11.3591	Type 2 DM with proliferative DR, right eye, without macular edema	✅ HCC 18	PDR without DME; anti-VEGF may still be used
E11.3592	Type 2 DM with proliferative DR, left eye, without macular edema	✅ HCC 18	PDR without DME
E10.311	Type 1 DM with unspecified diabetic retinopathy with macular edema	✅ HCC 18	Type 1 DM equivalent
E10.3511	Type 1 DM with proliferative DR, right eye, with macular edema	✅ HCC 18	Type 1 PDR + DME
E13.311	Other specified DM with unspecified diabetic retinopathy with macular edema	✅ HCC 18	Secondary diabetes (steroid-induced, post-pancreatectomy)

🔴 Retinal Vein Occlusion (RVO)

ICD-10-CM	Description	HCC	Notes
H34.10	Central retinal vein occlusion, unspecified eye	❌ No HCC	CRVO — anti-VEGF strongly indicated
H34.11	Central retinal vein occlusion, right eye	❌ No HCC	CRVO, right — specify with RT
H34.12	Central retinal vein occlusion, left eye	❌ No HCC	CRVO, left — specify with LT
H34.210	Partial branch retinal vein occlusion, right eye	❌ No HCC	BRVO partial
H34.211	Partial BRVO, right eye	❌ No HCC	—
H34.219	Partial BRVO, unspecified eye	❌ No HCC	—
H34.231	Tributary BRVO, right eye with macular edema	❌ No HCC	More specific; documents macular involvement
H34.232	Tributary BRVO, left eye	❌ No HCC	BRVO, left
H34.9	Unspecified retinal vascular occlusion	❌ No HCC	Use only if type cannot be determined

🔴 Macular Edema (Non-Diabetic)

ICD-10-CM	Description	HCC	Notes
H35.81	Retinal edema	❌ No HCC	Non-specific macular/retinal edema; use more specific code when available
H59.031	Cystoid macular edema following cataract surgery, right eye	❌ No HCC	Post-cataract CME (Irvine-Gass syndrome) — intravitreal steroid often used
H59.032	Cystoid macular edema following cataract surgery, left eye	❌ No HCC	Post-cataract CME, left
H35.371	Puckering of macula, right eye	❌ No HCC	Epiretinal membrane with edema; may precede vitrectomy
H35.372	Puckering of macula, left eye	❌ No HCC	ERM with edema, left

🔴 Choroidal Neovascularization (Non-AMD)

ICD-10-CM	Description	HCC	Notes
H35.051	Retinal neovascularization, right eye	❌ No HCC	CNV not further specified
H35.052	Retinal neovascularization, left eye	❌ No HCC	CNV, left
H31.301	Unspecified choroidal degeneration, right eye	❌ No HCC	Choroidal disease with CNV
H31.421	Choroidal hemorrhage, right eye	❌ No HCC	May require anti-VEGF

🔴 Uveitis / Inflammatory Conditions

ICD-10-CM	Description	HCC	Notes
H30.001	Unspecified focal chorioretinal inflammation, right eye	❌ No HCC	Posterior uveitis; intravitreal steroid (Ozurdex, Yutiq) indicated
H30.002	Unspecified focal chorioretinal inflammation, left eye	❌ No HCC	Posterior uveitis, left
H30.101	Unspecified disseminated chorioretinal inflammation, right eye	❌ No HCC	Disseminated; pan-uveitis
H20.00	Unspecified acute and subacute iridocyclitis	❌ No HCC	Anterior; rarely intravitreal
H44.001	Unspecified purulent endophthalmitis, right eye	❌ No HCC	Intravitreal antibiotics — vancomycin + ceftazidime/amikacin; urgent/emergent injection
H44.002	Unspecified purulent endophthalmitis, left eye	❌ No HCC	Endophthalmitis, left — emergent intravitreal antibiotics
H44.011	Panophthalmitis, right eye	❌ No HCC	Severe; may require vitrectomy (67036) in addition
H44.131	Sympathetic uveitis, right eye	❌ No HCC	Post-traumatic uveitis

🔴 Other Retinal Pathology

ICD-10-CM	Description	HCC	Notes
H35.041	Retinal micro-aneurysms, right eye	❌ No HCC	Diabetic/vascular; supplemental
H35.61	Retinal hemorrhage, right eye	❌ No HCC	May prompt injection if related to CNV or RVO
H33.001	Unspecified retinal detachment with rhegmatogenous detachment, right eye	❌ No HCC	Anti-VEGF occasionally used as adjunct to surgery
H35.721	Vitreomacular adhesion, right eye	❌ No HCC	Ocriplasmin (Jetrea) — specific indication for 67028
H35.722	Vitreomacular adhesion, left eye	❌ No HCC	Ocriplasmin indication, left

🔴 Systemic Conditions Frequently Documented as Secondary Diagnoses

ICD-10-CM	Description	HCC	Notes
E11.9	Type 2 diabetes mellitus without complications	✅ HCC 19	When no diabetic ophthalmic manifestation combination code is used — but NOTE: prefer combination codes (E11.311, etc.) over this + H36.0
I10	Essential (primary) hypertension	❌ No HCC	Common comorbidity; documents cardiovascular risk in AMD/RVO patients
Z96.1	Presence of intraocular lens	❌ No HCC	Pseudophakic eye; affects injection site distance (3.0 vs 3.5 mm)
H26.001	Unspecified infantile and juvenile cataract, right eye	❌ No HCC	Lens status documentation
Z79.899	Other long-term (current) drug therapy	❌ No HCC	Documents ongoing anti-VEGF therapy regimen

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💡 HCC Details

Diabetic Retinopathy Combination Codes → HCC 18

Field	Detail
HCC Category	HCC 18 — Diabetes with Chronic Complications
CMS-HCC Model	Version 28 (current)
RAF Score (Community, Non-Dual)	~0.302
Clinical Significance	Diabetic retinopathy with macular edema represents an end-organ complication of diabetes — one of the highest-impact diabetic HCC categories
Code Specificity Requirement	Must use combination codes (e.g., E11.3311) that capture both the diabetes type AND the ophthalmic manifestation in a single code; do not split into E11.9 + H36.0
Laterality Requirement	FY2021+ ICD-10-CM expanded diabetic retinopathy codes to include laterality and stage — always code to the most specific level documented
Documentation Trigger	Retina specialist’s documentation of “DME,” “diabetic macular edema,” “CSME” (clinically significant macular edema), or specific DR staging with macular involvement
Risk Score Compounding	If the patient also has E11.65 (DM with hyperglycemia), E11.40 (DM with diabetic neuropathy), or E11.22 (DM with diabetic CKD), each adds a separate HCC score — comprehensive coding of all diabetic complications maximizes accurate risk adjustment

E11.9 / E10.9 — Type 2 / Type 1 DM Without Complications → HCC 19

Field	Detail
HCC Category	HCC 19 — Diabetes Without Complication
RAF Score	~0.105
Coding Guidance	When the diabetic combination code (HCC 18) is used, HCC 19 is typically superseded in risk-adjustment hierarchies — HCC 18 includes HCC 19. However, accurate coding of the specific complication (HCC 18) is preferred for clinical accuracy.

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🔧 Applicable Modifiers

Modifier	Description	Application to 67028
RT	Right eye	✅ Required — always append for right eye injections
LT	Left eye	✅ Required — always append for left eye injections
50	Bilateral procedure	Same-day bilateral injections; check payer preference (some prefer two separate lines with RT/LT)
25	Significant, separately identifiable E/M same day	✅ High-audit modifier; E/M must be truly separate and documented independently; common with new findings requiring clinical decision-making beyond routine injection
76	Repeat procedure by same physician	Same provider repeats 67028 on the same eye on the same date (rare but possible in certain emergency/endophthalmitis scenarios)
77	Repeat procedure by different physician	Different provider performs 67028 on same eye same date
52	Reduced services	Injection attempted but not fully completed (patient movement, unable to tolerate); document reason thoroughly
53	Discontinued procedure	Procedure stopped prior to needle insertion due to medical emergency
59	Distinct procedural service	When billing a separately identifiable service (e.g., anterior chamber paracentesis 65800) on the same date; overrides bundling edits
XU	Unusual non-overlapping service	Preferred CMS alternative to 59 for distinctly separate services
24	Unrelated E/M during global	Not typically applicable given 0-day global; theoretically could apply in unusual circumstances
32	Mandated service	Workers’ comp or regulatory mandate
GY	Item/service not covered by Medicare	For items Medicare categorically excludes; rarely applicable
GA	Waiver of liability on file	ABN obtained; payer may deny coverage for specific indication (e.g., off-label bevacizumab for certain diagnoses)

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🏨 MS-DRG (Inpatient Context)

67028 is almost exclusively performed in the outpatient setting — office-based, ASC, or HOPD. Inpatient intravitreal injection is rare but may occur when a patient is hospitalized for a comorbid condition AND develops an urgent ophthalmologic indication requiring intravitreal treatment (e.g., endophthalmitis, aggressive CNV with acute vision loss in a hospitalized patient).

ICD-10-PCS Equivalent (Inpatient Administration)

ICD-10-PCS	Description	Notes
3E0C3GC	Introduction of Other Therapeutic Substance into Eye, Percutaneous Approach	Primary PCS code for intravitreal injection of most pharmacologic agents
3E0C33Z	Introduction of Anti-inflammatory into Eye, Percutaneous Approach	For intravitreal corticosteroid injections (triamcinolone, dexamethasone)
3E0C3BZ	Introduction of Anesthetic Agent into Eye, Percutaneous Approach	Subconjunctival anesthetic (if separately coded inpatient — extremely rare)
3E0C3KC	Introduction of Other Therapeutic Substance into Eye, Percutaneous	Antibiotics (endophthalmitis treatment)

PCS Section: 3 = Administration Body System: E = Physiological Systems and Anatomical Regions Root Operation: 0 = Introduction (putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance) Body Part: C = Eye Approach: 3 = Percutaneous Substance: Varies by drug class

Inpatient MS-DRGs (When Applicable)

MS-DRG	Description	Type
124	Other Disorders of the Eye with MCC	Medical
125	Other Disorders of the Eye without MCC	Medical
113	Orbital Procedures with CC/MCC	Surgical
114	Orbital Procedures without CC/MCC	Surgical
116	Intraocular Procedures with CC/MCC	Surgical
117	Intraocular Procedures without CC/MCC	Surgical

🏥 Inpatient Coder Note: When 67028 drives or occurs during an inpatient admission, DRG assignment depends heavily on the principal diagnosis. For example:

• Endophthalmitis (H44.001) as principal dx → likely DRG 116/117 (intraocular procedure)
• Hospitalized diabetic patient receiving intravitreal anti-VEGF for acute DME while admitted for DKA → principal dx = DKA-related code; eye injection captured via PCS but does not typically drive DRG
• The PCS code 3E0C3GC may or may not be an OR procedure for DRG grouping purposes; verify with your facility’s grouper — in most cases intravitreal injection is NOT an OR procedure and functions as a non-OR procedure code that influences but does not drive MS-DRG assignment the way a surgical procedure would

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📝 Coding Examples

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🟢 Example 1 - Routine Monthly Bilateral Anti-VEGF Injection, Wet AMD

Clinical Scenario: A 78-year-old female with bilateral exudative (wet) AMD presents for scheduled monthly aflibercept (Eylea) injections. OCT performed prior to injection confirms persistent subretinal fluid bilaterally. Physician reviews OCT, confirms treatment indication, performs intravitreal injection of aflibercept 2 mg/0.05 mL into each eye sequentially. IOP and arterial perfusion confirmed bilaterally post-injection.

CPT Codes:

• 67028 - RT - Intravitreal injection, right eye
• 67028 - LT - Intravitreal injection, left eye

HCPCS Drug Codes:

• J0178 × 1 - RT - Aflibercept 1 mg (report 2 units for 2 mg dose)
• J0178 × 1 - LT - Aflibercept 1 mg (report 2 units for 2 mg dose)

ICD-10-CM:

• H35.3210 - Exudative AMD, right eye (primary, right eye line)
• H35.3220 - Exudative AMD, left eye (primary, left eye line)

Note: No E/M billed today — OCT review is routine pre-injection monitoring; no new symptoms or separate clinical decision-making documented. OCT (92134) may be billed separately with appropriate laterality modifiers if performed and documented.

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🟢 Example 2 - Intravitreal Injection for DME with Same-Day E/M, New Finding

Clinical Scenario: A 64-year-old male with Type 2 DM presents for scheduled ranibizumab injection for moderate nonproliferative diabetic retinopathy with DME, right eye. Prior to injection, patient reports new-onset floaters in the right eye over the past 2 days. Physician performs a comprehensive dilated fundus exam documenting a new retinal lattice degeneration in the peripheral right retina without tear or detachment. Clinical decision: proceed with injection as planned; schedule return for laser retinopexy. OCT confirms persistent center-involving DME. Injection performed.

CPT Codes:

• 99214 - 25 - Office visit, moderate MDM, established patient (separate documentation of new symptom evaluation, examination, and separate clinical decision regarding lattice)
• 67028 - RT - Intravitreal ranibizumab injection, right eye

HCPCS Drug Code:

• J2778 - RT - Ranibizumab 0.1 mg (report appropriate units for dose)

ICD-10-CM:

• E11.3311 - Type 2 DM with moderate nonproliferative DR, right eye, with macular edema ← HCC 18
• H35.411 - Lattice degeneration of retina, right eye (justifies E/M — new finding)

💡 Modifier 25 Justification: The physician documented a separate chief complaint (new floaters), performed a separately identifiable examination beyond routine pre-injection assessment, identified a new clinical finding (lattice degeneration), and made a separate treatment decision (schedule laser). This supports 25. Documentation would NOT support 25 if the note simply stated “patient stable, no new complaints, OCT unchanged, proceed with injection.”

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🟢 Example 3 - Intravitreal Antibiotics for Endophthalmitis

Clinical Scenario: A 71-year-old male presents to retina clinic 4 days after uncomplicated cataract surgery (66984) with acute-onset pain, vision loss, and hypopyon in the right eye. Clinical diagnosis: acute post-operative endophthalmitis. Emergency intravitreal injection of vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL performed in the right eye.

CPT Codes:

• 67028 - RT - Intravitreal injection (vancomycin) (first injection)
• 67028 - RT - 76 - Intravitreal injection (ceftazidime), same eye, same date, same physician (second injection)

(Some coders and payers prefer a single 67028-RT for same-session multiple injections into the same eye; others accept 76 for the second injection. Verify payer policy — AMA guidance suggests reporting once per eye per session, but individual payer policies vary.)

Drug Codes:

• J3370 - Vancomycin HCl, per 500 mg (report appropriate units)
• J0713 - Ceftazidime, per 500 mg (report appropriate units)

ICD-10-CM:

• H44.001 - Unspecified purulent endophthalmitis, right eye (principal)
• H59.031 - (If post-cataract; however this is purulent/infectious, not CME — use H44.001 as primary)
• Z98.41 - Cataract extraction status, right eye (documents post-surgical context)

⚠️ Coding Alert: Endophthalmitis post-cataract surgery is a complication of the cataract procedure. The principal diagnosis should be the endophthalmitis (H44.001), not the prior cataract surgery code. Document the causal relationship clearly for accurate coding.

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🟢 Example 4 - Intravitreal Dexamethasone Implant (Ozurdex) for BRVO-related Macular Edema

Clinical Scenario: A 67-year-old female with right eye branch retinal vein occlusion and persistent macular edema despite two prior anti-VEGF injections. Decision made to switch to intravitreal dexamethasone implant (Ozurdex 0.7 mg). Injection performed via pars plana using the proprietary applicator system.

CPT Code:

• 67028 - RT - Intravitreal injection of pharmacologic agent (dexamethasone implant), right eye

HCPCS Drug Code:

• J7312 - Dexamethasone, intravitreal implant, 0.1 mg (report 7 units for 0.7 mg dose)

ICD-10-CM:

• H34.231 - Tributary (branch) retinal vein occlusion, right eye, with macular edema

💡 Billing Note: Ozurdex is delivered via a preloaded applicator; the injection technique differs from a standard syringe but is still correctly coded as 67028. Some coders incorrectly consider whether 67027 (implantation of intravitreal drug delivery system) applies — it does not. 67027 is for sustained-release devices requiring surgical implantation (e.g., Iluvien, Yutiq, Susvimo port delivery). Ozurdex is a biodegradable implant injected via standard intravitreal technique and maps to 67028.

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🟢 Example 5 - Inpatient Intravitreal Injection During Hospitalization

Clinical Scenario: A 73-year-old male admitted for NSTEMI management. Ophthalmology is consulted bedside for sudden vision loss in the left eye. Exam reveals acute exudative AMD with massive subretinal hemorrhage and active CNV. Decision made to administer emergent intravitreal aflibercept at bedside. Procedure performed in the patient’s room under sterile technique.

Professional Claim (Ophthalmology):

• 67028 - LT - Intravitreal injection, left eye

Drug:

• J0178 - LT - Aflibercept

ICD-10-CM:

• H35.3220 - Exudative AMD, left eye (reason for ophthalmology service)
• Principal Dx for admission: I-code related to NSTEMI (ophthalmology service is consulting)

Inpatient UB-04 (ICD-10-PCS for Facility):

• 3E0C3GC - Introduction of Other Therapeutic Substance into Eye, Percutaneous Approach

MS-DRG Impact: The eye procedure PCS code is non-OR and does not typically drive DRG; the cardiac principal diagnosis controls DRG assignment. The PCS code is captured for completeness but functions as a secondary procedure.

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⚠️ Common Coding Pitfalls

• ❌ Do not omit laterality modifiers (RT/LT) — this is a claim rejection trigger for virtually every payer; it is also an audit red flag if consistently missing
• ❌ Do not forget to separately bill the drug (J-code) — 67028 covers only the injection service; the drug is a separate charge and a significant revenue component
• ❌ Do not use 67027 for Ozurdex — it is injected (not surgically implanted) and maps to 67028; 67027 is for the Iluvien/Yutiq sustained-release insert requiring a different delivery mechanism
• ❌ Do not bill 67028 multiple times for the same eye on the same date without reviewing payer policy — most payers consider one injection per eye per session as the billable unit; modifier 76 for a second injection same eye same day requires payer verification
• ❌ Do not append modifier 25 to the E/M without robust, separate documentation — this is an OIG audit target; the E/M note must stand independently without reference to the injection note
• ❌ Do not use diabetic eye disease combination codes on the wrong laterality line — E11.3311 is right eye; E11.3312 is left; mismatched laterality between diagnosis and procedure codes triggers edits
• ✅ Always verify the number of units for J-codes — many anti-VEGF J-codes are billed per mg or per 0.1 mg increment; incorrect units = incorrect drug reimbursement
• ✅ Always document povidone-iodine use in the procedure note — some payers have made this a medical necessity requirement for 67028; absence of documentation has been used as a basis for claim denial in audits
• ✅ Always document post-injection IOP check and central retinal artery perfusion confirmation — these are standard of care elements that support the medical necessity and completeness of the procedure note
• ✅ For bilateral same-day injections, confirm whether your payer prefers modifier 50 on one line OR two separate lines with RT and LT — incorrect submission format can delay payment even when the claim is clinically correct
• ✅ OCT (92134) is separately billable when performed and separately documented as a diagnostic service on the same day as 67028 — it is NOT bundled into the injection code; ensure the OCT has its own separate documentation/report

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📌 Quick Reference Summary

Field	Value
Code	67028
Type	CPT - Surgery (Minor/Office-Based)
System	Eye and Ocular Adnexa
Body Part	Vitreous cavity
Approach	Percutaneous (pars plana transconjunctival)
Laterality Required	✅ RT or LT — mandatory
Bilateral Reportable	✅ Yes — two lines RT + LT or modifier 50
Global Period	000 (zero days)
wRVU (Facility)	0.74
wRVU (Non-Facility)	1.63
Assistant Payable	❌ No
Drug Included	❌ No — bill J-code separately
Separate Procedure	✅ Yes — per CPT descriptor
Modifier 25 Risk	⚠️ High audit risk — document rigorously
Modifier 76	Possible for repeat same-eye same-day — verify payer
PCS Equivalent	3E0C3GC (most agents)
Top Diagnosis	H35.3210/H35.3220 (wet AMD), E11.3311/E11.3312 (DME)
HCC-Triggering DX	E11.311-E11.3592 → HCC 18; E11.9 → HCC 19
MS-DRG (Inpatient)	116 / 117 (intraocular) or 124 / 125 (medical eye)
High-Volume Flag	✅ One of the highest-volume procedures in the US
Top J-Codes	J0178 (aflibercept), J2778 (ranibizumab), J0171 (faricimab), J7312 (dexamethasone implant)

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_{AMA CPT Professional Edition 2024 · CMS Physician Fee Schedule Look-Up Tool FY2025 · CMS-HCC Risk Adjustment Model v28 · CMS NCCI Policy Manual for Medicare Services v30 · AHA Coding Clinic for ICD-10-CM/PCS FY2025 · CMS ICD-10-PCS Official Guidelines FY2025 · CMS MS-DRG Grouper v41 · CMS Medicare Claims Processing Manual Ch. 12 · AAO Coding Resources 2024 · OIG Work Plan - Ophthalmology Intravitreal Injection Audits · CMS LCD L33780 (Intravitreal Injections)}