The human eye is one of the most delicate parts of the body, requiring immediate attention in medical emergencies. According to the World Health Organization, nearly 2.2 billion individuals are vision-impaired.
For more serious conditions, the numbers may vary, but eye-related diseases and medical complications are very common. The treatment for one such complication involves injections into the vitreous humor, the liquid that fills the inside of the eye. This treatment procedure is represented by CPT code 67028 in medical billing.
The question is, what are the guidelines and the right approaches to handle billing for such procedures? We’ll cover everything you need to know about this CPT code, but first, let’s step back and look at what this code is all about.
CPT Code 67028 – Description
When a person experiences eye-related complications and requires medication to be administered directly into the eye, an intravitreal injection is used. This medical procedure is reported with the CPT code 67028 during medical billing.
What Happens in Cases Like These?
In cases like this, the physician or the ophthalmologist administers an intravitreal injection. The injection contains a pharmacologic agent that is introduced into the eye. In most cases, the injection is administered into the vitreous humor. This is the gel-like substance that fills the area between the lens and the retina. The procedure is generally considered safe and should only be performed if the physician confirms medical necessity.
Understanding the application of CPT code 67028 for vitreous procedures is crucial to differentiate it from other CPT codes. So, let’s talk about it.
Appropriate Use Cases for CPT Code 67028
The following are some medically appropriate use cases for CPT code 67028 to keep in mind:
Case 1: Uveitis Management
Consider non-infectious posterior uveitis in a 46-year-old male who visits an eye specialist at the clinic. The patient shows vision-threatening macular inflammation. In regard to previous interventions, the patient was unresponsive to oral steroids. Therefore, the ophthalmologist chooses the intravitreal dexamethasone implant (Ozurdex), which is injected, and the administration is coded with CPT code 67028.
This decision ensures targeted steroid delivery to help with vitritis and improve visual acuity.
Case 2: CNVM in Cystoid Macular Edema
Now, let’s consider a 60-year-old patient with a long history of diabetes. Moreover, the patient also has Choroidal Neovascular Membranes (CNVM) secondary to age-related macular degeneration (AMD). He visits the ophthalmologist, where the medical expert uses fluorescein angiography (FA) and optical coherence tomography (OCT) to confirm this. As a result of the medical condition, the patient experiences a rapid loss of vision.
For treatment, the physician administers anti-VEGF (e.g., aflibercept) intravitreally. This helps regress neovascularization and also treats edema. The injection administration is then billed using CPT code 67028.
Case 3: Geographic Atrophy Treatment
A 75-year-old visits an ophthalmologist’s clinic. Upon examination, the medical expert finds the patient has advanced dry AMD. In addition, he also exhibits confirmed geographic atrophy (GA) on OCT, contributing to the medical complication. Moreover, he also shows progressive outer retinal atrophy.
Considering his condition, without treatment, the patient is at risk of progressive central vision loss. Therefore, the ophthalmologist administers an intravitreal pegcetacoplan (Syfovre) injection. This medication slows down the growth of the lesion and helps preserve vision.
Once the medical procedure is complete, the billing team uses CPT code 67028 to bill the injection administration.
Modifiers to Append with CPT Code 67028
Modifiers play a vital role in the billing of CPT code 67028. However, each of the modifiers must be used in specific circumstances. Here’s a look at these modifiers and when they can be used.
Modifiers RT and LT
LT and RT are two of the most crucial modifiers in eye treatment. They help determine laterality, or the side of the body where the treatment was performed. So, if the injection was administered on the right eye, you must use the modifier RT. Conversely, if the left eye was treated, modifier LT should be used.
It is necessary to know that eye-related medical procedures may be unilateral or bilateral, depending on the situation. Therefore, using these modifiers to specify the eye is necessary for accurate billing and to avoid claim denials.
Modifier 50
If the eye specialist administered intravitreal injections on both eyes (bilaterally) within the same session, this modifier should be used. However, the requirements for billing such cases may vary from payer to payer.
For instance, some payers require two separate lines with the laterality modifiers (RT and LT) instead of modifier 50. For example:
- 67028-LT
- 67028-RT
And not:
- 67028-50
Note that if the billing team uses an incorrect billing convention for the payer, it may lead to a denial or delay.
Modifier 59
Another popular modifier appended to CPT code 67028 is modifier 59. This modifier represents that procedures that are typically bundled are distinct and separately billable in this case. Simply speaking, modifier 59 indicates:
- Distinct procedural service
- Performed on the same day
- By the same physician
It helps the healthcare provider bypass NCCI bundling edits.
Modifier XE
The modifier XE is a subdivision of the modifier 59. It offers greater specificity and signifies that the two procedures are distinct from each other because they were performed during separate encounters on the same day.
Reimbursement Guidelines for CPT Code 67028
Now that we have discussed CPT code 67028’s applicable modifiers and use cases, it’s necessary to consider the reimbursement guidelines for this CPT code.
Use the Right Modifiers
Using the correct modifier, especially laterality modifiers, is crucial with CPT code 67028 because it clarifies the situation during treatment. Moreover, it increases coding accuracy, reducing the chances of a claim denial.
Check the Payer’s Requirements
As we have mentioned before, different payers may have varying rules for modifier usage on the claim form. So, if the payer does not accept bilateral modifier 50 and prefers modifier RT and LT on separate claim lines, make sure you follow those coding conventions. Similarly, thoroughly review the payer’s policy manual to ensure compliance during billing.
Justify Injection’s Medical Necessity
Only medically necessary services and procedures are eligible for reimbursement. Therefore, you must prove the intravitreal injection’s medical necessity through the relevant ICD-10 diagnosis codes and complete documentation. Your supporting documents must include the patient’s complete medical record, test results, clinical notes, and progress notes.
Verify the Reimbursement Rate
The reimbursement rate for this medical procedure varies depending on whether the injection is administered in a medical facility or an outpatient clinic (physician’s office). So, if you want to know the national average reimbursement rate for 67028 based on the setting and Medicare Administrative Contractor (MAC) locality, refer to the Physician Fee Schedule (PFS) lookup tool.
Are your Ophthalmology Service Claims Accurate?
The CPT codes and modifiers play a vital role in billing. We’ve discussed CPT code 67028, its use cases, modifiers, and guidelines in great detail. However, if we missed out on something or you simply feel overwhelmed, our ophthalmology billing services provide comprehensive assistance with medical billing. NeuraBill’s expert team ensures coding accuracy and payer compliance in every claim.
