Intravitreal injections: Making sure your claims are approved


Intravitreal Injections: Making Sure Your Claims Are Approved

Information Provided By Riva Lee Asbell

Recent changes can affect coding for intravitreal injections.


Ranibizumab (Lucentis, Genentech) is approved for the treatment of wet AMD and for macular edema following retinal vein occlusion (RVO). Aflibercept (Eylea, Regeneron) is approved for wet AMD. Effective August 10, the FDA approved ranibizumab for diabetic macular edema. Some Medicare administrative contractors (MACs) have extended the coverage to bevacizumab for this usage as well.

Coverage for other indications is controlled by your MAC's LCD (local coverage determination) and guidelines; thus, it is critical to remain up-to-date with them. For example, NGS Medicare also covers treatment of macular retinal edema due to RVO, proliferative diabetic retinopathy, rubeosis and neovascular glaucoma among others.


Make sure the diagnosis you are billing for is included in the LCD or the claim may be rejected. When a new drug or diagnosis is approved, claims are rejected until the MAC gets its computers programmed to accept these changes.

A Medicare Part B payment rate does not necessarily mean the product has Medicare coverage. Local contractors make that determination. Be sure your MAC has announced by special email or in one of its communications that it is ready to roll with this.


Make sure your billing personnel have taken care of the following:
► Covered diagnosis.
► Proper dosage.
► Billing the intravitreal injection code and the supply code on the same claim.
► The proper site (location) modifier (-RT or -LT) is appended to the intravitreal injection code (67028).
► Make certain the ICD-9 codes placed on the claim are listed in the LCD.
► Make sure the HCPCS supply code is correct; different MACs may specify different HCPCS codes for various drugs


Here are the most common diagnosis codes used with intravitreal injections:
362.35 Central retinal vein occlusion.
362.07 Diabetic macular edema (Note: Use of this code for diabetic macular edema is subject to added coding requirements according to the ICD-9-CM Code Book).
362.36 Venous tributary (branch) occlusion of the retina.
362.52 Exudative senile macular degeneration.
362.83 Retinal edema.


All MACs have policies on off-label use of drugs. Sometimes an off-label usage is covered and at other times it is not. Read the policy before you decide to bill Medicare for one of these uses.

If an off-label use of a drug is performed, and the specific use is not covered by Medicare, you may bill the patient for the procedure and the supply. Note that you should have the patient sign an advanced beneficiary notice (ABN) that clearly states the usage is off label due to a noncovered diagnosis. In addition, your informed consent should contain all the pertinent information.


Documentation for all injections must reflect the drug, dosage, frequency, method, and site of administration. MACs recommend that providers perform periodic self-audits of their records to verify if this documentation is contained with the medical record.

Develop a form that contains the above-required information and have the form serve as an operative report. An intravitreal injection is a surgical procedure so there should also be a place to describe any complications or note if none occurred. Be sure it is signed and include an informed consent. Check with your malpractice carrier about using one consent for multiple injections. Be aware that CERT audits have begun on chart documentation. RP

CPT codes copyrighted 2012 by the American Medical Association.

Riva Lee Asbell can be contacted at www., where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.