Summary & Overview
HCPCS J7316: Injection, Ocriplasmin 0.125 mg
HCPCS Level II code J7316 denotes injection of ocriplasmin, 0.125 mg, an intravitreal pharmacologic therapy used in ophthalmology for select vitreoretinal conditions. Nationally, this code matters for clinics and ambulatory surgical centers that deliver specialty retinal injections and for payers managing coverage and utilization of high-cost ophthalmic biologics. Claims and coverage decisions for J7316 affect access to this targeted, single-dose treatment and influence site-of-service cost patterns.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of code definition and clinical context, summaries of payer coverage approaches, typical billing considerations for intravitreal injection services, and national-level benchmarks where available. The report highlights payer coverage variability, place-of-service implications for office versus ASC billing, and coding nuances that affect claims processing. Data not available in the input is identified where applicable. This summary equips revenue-cycle professionals, ophthalmology providers, and policy analysts with a concise reference to the clinical use and billing context of HCPCS Level II code J7316.
Billing Code Overview
HCPCS Level II code J7316 represents an injection of ocriplasmin, 0.125 mg. This service involves administration of a single-dose intravitreal pharmacologic agent used in ophthalmology to treat specific vitreoretinal conditions.
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Service type: Intravitreal pharmacologic injection
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Typical site of service: Office-based ophthalmology clinic or ambulatory surgical center (ASC)
Clinical & Coding Specifications
Clinical Context
A 68-year-old phakic patient presents to a retinal specialist with symptomatic vitreomacular traction and a small full-thickness macular hole confirmed on spectral-domain optical coherence tomography (OCT). Visual acuity has declined over several weeks with central distortion and metamorphopsia. The retina specialist recommends office-based intravitreal enzymatic vitreolysis using ocriplasmin (J7316) as an alternative to pars plana vitrectomy for selected patients without extensive epiretinal membrane or large macular holes.
Clinical workflow: the patient undergoes pre-procedure informed consent and dilated fundus exam, baseline OCT imaging, and review of systemic and ocular contraindications. In the procedure room or designated procedure suite, topical anesthesia and povidone-iodine antisepsis are applied. A single 0.125 mg intravitreal injection of ocriplasmin (J7316) is administered via pars plana technique. Post-injection intraocular pressure (IOP) is measured and the patient receives post-procedure instructions and scheduled follow-up at 1 week and 4 weeks with repeat OCT to assess release of vitreomacular traction or closure of macular hole. If the enzyme therapy fails or complications occur, pars plana vitrectomy may be scheduled subsequently.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier |