Coding Q & A

Intravitreal injections: Keeping in compliance


Intravitreal Injections: Keeping in Compliance


Intravitreal injections remain the mainstay of the retinal surgery practice. Along with issues of practice efficiency, we see serious compliance infringements regularly occurring in many practices. These are more than abusive practices — they are potential criminal prosecution issues.


I have recently been aware of and involved in the defense of several serious audits regarding this practice. It is critical to keep a meticulous log of all supplies and their usage and which patient was given what lot.

Under no circumstances should different patients be given injections of drugs from the same single-use vial nor should the supply for bilateral injections on the same patient come from the same single-use vial. It has been quite simple for Medicare to track the number of vials purchased and compare it with the number of times CPT code 67028 (intravitreal injection) was coded.

Case example:

The following is probably the most well known case in which the same vial was used for multiple patients, but multiple vials were ordered and subsequently sold: VRF Eye Specialty Group PLC v. Seth L. Yoser, filed in US District Court for the Western District of Tennessee. (Available at: Accessed November 1, 2012).

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Novitas Solutions and other MACs have become very specific on the required documentation for injections. Documentation for injections must reflect the drug, dosage, frequency, method and site of administration. They recommend that providers perform periodic self-audits of their records to verify if this documentation is contained with the medical record.


► Develop a forced-entry operative note that includes all the above information. As well, make sure there is a place to check off if there were any complications and which eye was injected. Make sure a signature and date are included. This information is being asked for in CERT audits for intravitreal injections. It is obligatory from both a Medicare compliance perspective and a risk management one.

► Develop a logbook that specifies the above listed elements.

► Forensic internal audits of the logbook should be routinely scheduled and performed.

► Do not take advice from colleagues at medical meetings. Well-intended, but erroneous advice is often gleaned at coffee breaks in all fields of medicine. Always seek professional advice.

► Be sure to read the coding and reimbursement columns in the various ophthalmic publications.


Q. We have patients who have been receiving Lucentis (ranibizumab, Genentech) injections on a long-term basis for wet AMD. If they have surgery for a retinal detachment (same eye) and return for their injection two weeks later, do you use a modifier 58 or a modifier 79?
A. The correct modifier is 79 in this case since it is unrelated to the retinal detachment surgery by virtue of a different diagnosis. If the injection has been planned prospectively as part of the treatment for the retinal detachment or other related surgery you would use modifier 58.

Q. We occasionally inject both eyes at the same visit. I code 67028-50 and J9035-50. We haven’t done multiple injections with more than one drug — coding should be interesting!
A. The issue is not one of reimbursement. You will be paid at multiple surgery rules, which means you will receive 100% of the allowable for the first procedure and 50% for the second. For any drug used from a single-use vial, you must use two vials. RP

CPT codes copyrighted 2012 by the American Medical Association.