CPT Code 67028

CPT code 67028 is a medical billing code for an injection of medication into the eye, typically used in treatments for eye diseases.

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What is CPT Code 67028

CPT code 67028 is used to denote an intravitreal injection of a pharmacologic agent into the eye. This procedure is commonly performed to administer medications directly into the vitreous humor, which is the clear gel that fills the space between the lens and the retina of the eye. This method is typically used for treating various eye diseases, including age-related macular degeneration, diabetic retinopathy, and retinal vein occlusion.

Does CPT 67028 Need a Modifier?

For CPT code 67028, which pertains to intravitreal injection of a pharmacologic agent, several modifiers may be applicable depending on the specific circumstances of the procedure. Here is an ordered list of common modifiers used with this code and the reasons for their use:

1. -RT (Right Side) and -LT (Left Side):
- These modifiers are used to specify which eye received the injection. Since treatments can be unilateral or bilateral, specifying the eye is crucial for accurate billing and to avoid claim denials.

2. -50 (Bilateral Procedure):
- This modifier is used when the procedure is performed on both eyes during the same session. It is important to check with individual payers as some may require the procedure to be billed on two separate lines with -RT and -LT modifiers instead of using -50.

3. -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure):
- This modifier is used when a significant, separate evaluation and management service is performed on the same day as the injection. It indicates that an additional service, which is distinct and necessary, was provided beyond the usual preoperative and postoperative care associated with the injection.

4. -59 (Distinct Procedural Service):
- Modifier -59 is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. This modifier can help in situations where procedures that are usually bundled need to be reported separately due to different sessions, different procedures, different sites, or separate incisions/excisions.

5. -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period):
- This modifier is applicable if the intravitreal injection is performed during the postoperative period of another unrelated procedure and is not considered a part of the postoperative care.

6. -XE (Separate Encounter):
- This is a subset of the -59 modifier, used to signify that a service that is normally bundled into another service is distinct because it occurred during a separate encounter on the same day.

7. -JW (Drug amount discarded/not administered to any patient):
- This modifier is used to report the amount of a drug that is discarded and not administered to the patient. It is particularly relevant for expensive medications where documenting wasted amounts can be crucial for reimbursement.

Each of these modifiers serves to provide specific, necessary details that affect how the procedure is billed and reimbursed. It is essential to use these modifiers correctly to ensure compliance with payer policies and to facilitate accurate reimbursement for the services provided.

CPT Code 67028 Medicare Reimbursement

CPT code 67028, which pertains to intravitreal injection of a pharmacologic agent, is generally reimbursed by Medicare. This procedure is commonly used for administering medications directly into the vitreous near the retina in the eye and is frequently utilized in the treatment of conditions such as age-related macular degeneration, diabetic retinopathy, and retinal vein occlusion.

The reimbursement for CPT code 67028 by Medicare can vary based on geographic location and the setting in which the procedure is performed (e.g., physician's office vs. outpatient facility). To determine the specific reimbursement amount, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the Centers for Medicare & Medicaid Services (CMS) website or through Medicare Administrative Contractors (MACs) that manage claims and payments in specific regions.

Additionally, it's important to note that while Medicare covers the procedure, there may be additional considerations regarding the specific drug used for the injection. Some drugs might have separate coverage requirements or may be subject to Medicare Part B or Part D depending on how they are classified under Medicare's formulary guidelines. Providers should verify coverage for the specific pharmacologic agent used in conjunction with CPT code 67028 to ensure comprehensive reimbursement.

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