Summary & Overview
CPT 67028: Intravitreal Injection of Pharmacologic Agent
CPT code 67028 is a widely utilized billing code in ophthalmology, representing the intravitreal injection of a pharmacologic agent into the posterior segment of the eye. This procedure is essential for the treatment of several retinal diseases, including age-related macular degeneration and retinal vein occlusion, and is performed in an office setting. Nationally, this code is recognized by major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, reflecting its broad clinical and reimbursement relevance.
This publication provides a comprehensive overview of CPT code 67028, including payer coverage, clinical context, and related billing practices. Readers will gain insight into the procedure's role in ophthalmic care, typical sites of service, and associated coding benchmarks. The summary also highlights common modifiers and related codes, offering clarity on documentation and billing nuances. Policy updates and clinical trends are discussed to inform stakeholders about evolving standards in retinal disease management. The analysis is designed for a national audience, supporting providers, payers, and healthcare administrators in understanding the significance and utilization of this procedure.
CPT Code Overview
CPT code 67028 represents the intravitreal injection of a pharmacologic agent as a separate procedure. This service is commonly performed in the field of ophthalmology, specifically targeting the posterior segment of the eye. The typical site of service for this procedure is the office setting (Place of Service 11). Intravitreal injections are a critical intervention for various retinal conditions, providing direct delivery of medication into the vitreous cavity to manage and treat ocular diseases.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult presenting to an ophthalmology office with decreased vision or visual distortion. The patient is diagnosed with a retinal condition such as exudative age-related macular degeneration or central retinal vein occlusion. After clinical evaluation and imaging, the ophthalmologist determines that an intravitreal injection of a pharmacologic agent is indicated to treat the underlying retinal pathology. The procedure is performed in the office setting, with appropriate anesthesia and aseptic technique, targeting either the right eye, left eye, or both eyes depending on the diagnosis.
Coding Specifications
| Modifier Code | Description | Usage Scenario |
|---|---|---|
RT | Right eye | Used when the procedure is performed on the right eye |
LT | Left eye | Used when the procedure is performed on the left eye |
50 | Bilateral procedure | Used when the procedure is performed on both eyes |
- Provider Taxonomy:
207K00000X– Ophthalmology: Represents providers specializing in the medical and surgical care of the eyes and visual system.
Related Diagnoses
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H35.321– Exudative age-related macular degeneration, right eye- Relevant for patients receiving intravitreal injection in the right eye to treat macular degeneration.
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H35.322– Exudative age-related macular degeneration, left eye- Relevant for patients receiving intravitreal injection in the left eye for macular degeneration.
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H35.323– Exudative age-related macular degeneration, bilateral- Indicates bilateral disease, supporting the use of bilateral procedures or injections in both eyes.
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H34.8110– Central retinal vein occlusion, right eye- Used when the injection is performed to treat retinal vein occlusion in the right eye.
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H34.8120– Central retinal vein occlusion, left eye- Used when the injection is performed to treat retinal vein occlusion in the left eye.
Related CPT Codes
67027– Implantation of intravitreal drug delivery system (e.g., gangcyclovir implant, includes concomitant removal of vitreous)
Clinical Relationship:
67027is related to67028as both involve intravitreal administration of pharmacologic agents. While67028is for injection,67027is for implantation of a sustained-release drug delivery system. These codes are not typically used together in the same session but may be considered as alternatives depending on the treatment plan.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 67028 is $118.00, which is notably lower than the BUCA (average commercial) mean rate of $163.18. Commercial payers such as Blue Cross Blue Shield, Cigna, and UnitedHealth Group all reimburse at higher mean rates compared to Medicare, with Cigna offering the highest mean rate at $205.93.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range at $11.00, indicating relatively consistent reimbursement rates. In contrast, Cigna shows the widest dispersion at $130.33, reflecting greater variability in rates. Other commercial payers like UnitedHealth Group and Blue Cross Blue Shield also display broader ranges, with $112.00 and $78.67 respectively.
The table and chart below present a detailed breakdown of national mean rates and percentile values for each payer.
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