67028

Intravitreal injection of a pharmacologic agent (separate procedure)

CPT code 67028 represents the surgical administration of a pharmacological agent directly into the vitreous cavity of the eye. This procedure, commonly known as an intravitreal injection, is a cornerstone in the management of numerous sight-threatening retinal diseases. The vitreous humor is the clear, gel-like substance that fills the space between the lens and the retina. By injecting medications directly into this cavity, ophthalmologists and retina specialists can achieve high localized drug concentrations, bypassing the blood-retinal barrier that otherwise limits the efficacy of systemic or topical medications. The most frequently administered agents include anti-vascular endothelial growth factor (anti-VEGF) medications such as bevacizumab, ranibizumab, and aflibercept, which are pivotal in treating neovascular (wet) age-related macular degeneration, diabetic macular edema, and macular edema secondary to retinal vein occlusions. Additionally, corticosteroids like triamcinolone acetonide or dexamethasone implants may be injected to manage severe intraocular inflammation, uveitis, or refractory macular edema. Antimicrobial agents are also injected emergently for the treatment of endophthalmitis. The intravitreal injection is carefully performed under strict aseptic conditions to minimize the risk of devastating intraocular infections. Following the application of topical anesthetics and a broad-spectrum microbicide, typically povidone-iodine, the physician utilizes a specialized caliper to measure the precise injection site—usually 3.5 to 4.0 millimeters posterior to the limbus, depending on the patient's lens status (phakic vs. pseudophakic). This targets the pars plana, a safe zone lacking major vascular structures and retinal tissue. A fine-gauge needle (commonly 30-gauge or 32-gauge) is then inserted through the sclera, and the pharmacologic agent is delivered into the mid-vitreous cavity. Post-procedural monitoring ensures that the patient does not experience a dangerous spike in intraocular pressure or central retinal artery occlusion. Because of the targeted delivery, systemic side effects are minimized, maximizing therapeutic outcomes and preserving visual acuity.

Clinical Indications

  • Neovascular (wet) age-related macular degeneration (AMD).
  • Diabetic macular edema (DME).
  • Macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO).
  • Infectious endophthalmitis requiring emergent intravitreal antibiotics or antifungals.
  • Non-infectious uveitis or severe intraocular inflammation refractory to topical therapies.
  • Proliferative diabetic retinopathy (PDR) as an adjunctive or primary treatment.
  • Choroidal neovascularization secondary to pathologic myopia.

Procedure Steps

  1. Obtain informed consent, verifying the correct patient, correct eye, and correct medication to be injected.
  2. Apply topical anesthetic drops or gel (e.g., proparacaine, tetracaine, or lidocaine) to the ocular surface.
  3. Sterilize the conjunctiva, eyelids, and eyelashes using a 5% povidone-iodine solution or an acceptable alternative if the patient is allergic.
  4. Place a sterile eyelid speculum to keep the eye open and prevent contamination of the needle by the eyelashes.
  5. Measure the injection site using surgical calipers, typically 3.5 mm (for pseudophakic patients) to 4.0 mm (for phakic patients) posterior to the surgical limbus in the inferotemporal quadrant.
  6. Insert a small-gauge needle (e.g., 30G to 32G) smoothly through the pars plana into the vitreous cavity.
  7. Inject the precise volume (usually 0.05 mL to 0.1 mL) of the pharmacological agent into the mid-vitreous.
  8. Withdraw the needle carefully and apply immediate focal pressure to the injection site with a sterile cotton swab to prevent reflux of the medication and maintain hemostasis.
  9. Assess the patient's vision (e.g., counting fingers) and intraocular pressure to ensure adequate perfusion of the optic nerve.
  10. Remove the speculum, gently flush the eye if necessary, and provide comprehensive post-operative instructions regarding symptoms of infection, bleeding, or retinal detachment.

Coding Guidelines

  • Report code 67028 for the surgical injection procedure itself; the specific pharmacologic agent injected must be reported separately using the appropriate HCPCS Level II J-code (e.g., J0178, J2778, J2790).
  • Append laterality modifiers (RT for right eye, LT for left eye) to both 67028 and the corresponding J-code to ensure appropriate reimbursement.
  • If injections are performed bilaterally during the same encounter, report 67028 with modifier 50 (Bilateral Procedure) or as 67028-RT and 67028-LT on separate lines, depending on the specific payer's formatting preference.
  • Code 67028 is designated as a 'separate procedure.' It may be bundled into more extensive vitreoretinal surgical procedures (e.g., vitrectomy) if performed on the same eye during the same session, unless a distinct, medically necessary indication warrants modifier 59.
  • Do not report 67028 in conjunction with codes 67025 (Injection of vitreous substitute) or 67027 (Implantation of intravitreal drug delivery system).
  • An Evaluation and Management (E/M) code should only be reported on the same day if a significant, separately identifiable service is performed, requiring modifier 25.

Associated ICD-10 Codes