Intravitreal injections (IVIs) are a mainstay of retina practice. Still, it is worthwhile reviewing the reimbursement issues of this common procedure. This is especially true now, with Medicare and other payers focusing audits on the procedure.

Q. What conditions are treated with intravitreal injection?

A. Ophthalmologists, particularly retina specialists, use IVIs to treat a number of retinal conditions. Many of the diseases are severe, with poor prognoses and limited treatment options. These include exudative age-related macular degeneration, clinically significant macular edema, central retinal vein occlusion, retinal detachment (RD), endophthalmitis, fungal infections, vitreous hemorrhage, and cytomegalovirus retinitis.

Q. What documentation is needed to support these claims?

A. According to our experience as well as publications of the American Academy of Ophthalmology,¹ there are a number of critical documentation requirements. In addition to an appropriate diagnosis and the results of pertinent testing, documentation requirements include the following:

• Treatment plan. For new patients, document why the specific medication was chosen; for established patients, document the patient’s response to current medication and document why you are continuing it or changing.
• Informed consent. Document that the risks, benefits, and alternatives were discussed, and that the patient desires to proceed.
• Interval of treatment. Most IVIs are given at a minimum of 28 days, although some have longer intervals.
• Procedure note. Remember that, however common in your office, IVIs are surgical procedures. The note should include diagnosis, route of administration, medication name, dosage in mg and volume in mL and lot number, wastage greater than 1 unit for single use medications (eg, Triescence), and “any residual medication less than 1 unit has been discarded” for wastage less than 1 unit.
• Physician signature and date of procedure.

Be sure to maintain legible medication administration and inventory records.

Q. What considerations affect coding and reimbursement of IVIs?

A. There are several: medical indication (eg, FDA-approval, off-label); substance used (pharmaceutical or vitreous substitute); concurrent surgical procedure, if any; administration within a postoperative period of an earlier procedure; and location where IVI was given (eg, office, ASC, HOPD).

Q. Will insurance cover an off-label, investigational, or experimental use of medication delivered by IVI?

A. Not usually, although intravitreal use of bevacizumab (Avastin; Genetech) is an exception. Prudence generally necessitates getting preauthorization from the third-party payer. Alternately, ask the patient to assume financial responsibility if reimbursement is not expected.

Q. What CPT codes describe IVIs?

A. Two codes describe IVIs. They are distinguished by the injected substance: vitreous substitute or pharmacologic agent. The first is seldom used; the second is the most common minor procedure in the entire Medicare program.

1. 67025: Injection of vitreous substitute, pars plana or limbal approach, fluid-gas exchange, with or without aspiration, separate procedure.
2. 67028: Intravitreal injection of a pharmacologic agent, separate procedure.

Q. Both codes are designated “separate procedure.” What is the significance of this designation?

A. The CPT manual discussion of separate procedure states, “Some of the procedures or services listed in CPT that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term, ‘separate procedure.’ The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component. However, when a procedure or service that is designated as a ‘separate procedure’ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself or in addition to other procedures/services.”

According to Medicare’s National Correct Coding Initiative (NCCI), 67028 is bundled with retrobulbar injection (CPT 67500), subconjunctival injection (68200). It is also bundled with most retinal lasers. See NCCI for other edits. For example, repair of RD commonly includes an IVI. Both CPT and Medicare’s National Correct Coding Initiative (NCCI) treat the IVI as an incidental part of the RD repair and no separate claim should be made.

Q. Is this procedure reimbursed during the postoperative period of another surgery?

A. Sometimes. Medicare global surgery package includes any additional medical or surgical services during the postoperative period to treat a complication that does not require a return to the operating room.² So, unplanned injections performed in-office to cope with complications are not separately reimbursed. However, if the complication requires a return to the OR, then it may be paid (requires modifier 78). Lastly, preplanned IVIs that are not part of the global surgery package and are covered under the rules for staged procedures are payable (requires modifier 58). Other payers may have different coverage guidelines.

Q. Does place of service affect reimbursement for IVI?

A. Yes. Under Medicare’s site-of-service rules, reimbursement for the surgeon’s professional fee is lower when the injection is given in a hospital outpatient department (HOPD) or ambulatory surgery center (ASC) rather than the surgeon’s office. The Medicare Physician Fee Schedule identifies this as “facility” vs “nonfacility” reimbursement.

Q. How is the injected substance reimbursed?

A. In the office setting, injected pharmacologic agents are separately reported on a claim using HCPCS codes and reimbursed according to CMS’ office drug payment policy. In the HOPD and ASC, most drugs are included but some, such as Lucentis (ranibizumab; Genentech) and Eylea (aflibercept; Regeneron), are paid separately. They appear in the annual Medicare HOPD and ASC payment rate publications. RP

REFERENCES

1. American Academy of Ophthalmology. Checklist: intravitreal injections documentation and coding guidelines. Accessed September 12, 2022. https://bit.ly/3eKQzVn
2. Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 12 - physicians/nonphysician practitioners. Accessed September 12, 2022. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf