Summary & Overview
HCPCS Level II J1097: Phenylephrine and Ketorolac Ophthalmic Irrigant, 1 ml
HCPCS Level II code J1097 denotes a combined ophthalmic irrigation solution of phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml, billed per 1 ml unit. The code captures intraoperative use of a mydriatic and an NSAID in ophthalmic procedures to maintain pupil dilation and mitigate pain and inflammation. Nationally, accurate coding of this drug product affects facility and physician billing for cataract and other intraocular surgeries where intraoperative irrigation is used.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. The publication provides payor-specific benchmark context, reimbursement considerations, and coding relationships to related injectable NSAID and steroid products. Readers will find: payer coverage patterns and common billing modifiers used with HCPCS medication codes; comparisons to related HCPCS and injection codes for intraoperative ocular pharmacologic management; and clinical context describing when an ophthalmic irrigant containing phenylephrine and ketorolac is used in surgery.
This summary is intended for coding professionals, revenue cycle managers, and clinicians involved in ophthalmic surgery billing. It focuses on code definition, typical sites of service, and the core policy and billing topics readers need to interpret and apply HCPCS Level II code J1097 in a national context.
Billing Code Overview
HCPCS Level II code J1097 represents an ophthalmic irrigation solution containing phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml, billed per 1 ml unit. This product is used as an intraoperative ophthalmic irrigating solution combining a mydriatic (phenylephrine) and a nonsteroidal anti-inflammatory agent (ketorolac) to maintain pupil dilation and reduce intraoperative inflammation and pain during eye procedures.
Service type: Ophthalmic irrigation solution (intraoperative irrigant)
Typical site of service: Operating room or ambulatory surgical center during ophthalmic surgery
Clinical & Coding Specifications
Clinical Context
A 72-year-old patient presents to an ambulatory ophthalmology surgical center for planned cataract extraction with intraocular lens implantation. The surgeon uses an ophthalmic irrigation solution containing phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml (J1097) intraoperatively to maintain pupillary dilation and reduce intraoperative and immediate postoperative pain and inflammation. The clinical workflow includes preoperative evaluation, verification of medication allergies (notably NSAID and sulfonamide sensitivities), administration of standard topical anesthetic and antisepsis, intraoperative irrigation with the J1097 solution via the anterior chamber or irrigation/aspiration handpiece as indicated, documentation of lot number and volume used, and postoperative monitoring in the recovery area with discharge instructions. Typical site of service is an ambulatory surgery center (ASC) or hospital outpatient department (HOPD) for anterior segment ophthalmic surgery.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Default/No modifier | Rarely reported; use carrier-specific guidance if no modifier applies |