CPT code 67028: Intravitreal injection billing guide

Key Takeaways

CPT code 67028 describes intravitreal injection of a pharmacologic agent (separate procedure) in the posterior segment of the eye.

The 2026 Medicare national average reimbursement is approximately $83 non-facility and $63 facility; rates vary by geographic locality via GPCI.

Modifier 25 is required on the same-day E/M code; missing it is the top denial trigger for retina and ophthalmology practices.

Pabau’s claims management software automates modifier prompts and ICD-10 linkage so high-volume injection practices reduce 67028 denials before submission.

Official AMA description for CPT code 67028 is Intravitreal injection of a pharmacologic agent (separate procedure). The American Medical Association’s CPT code set places 67028 within the Vitreous Procedures on the Posterior Segment section (codes 67005-67043). The designation “separate procedure” means the code may be reported independently when not performed as part of a more comprehensive vitreous surgery at the same session.

Clinically, the procedure involves injecting an anti-VEGF agent, steroid, or other pharmacologic drug directly into the vitreous cavity of the eye. The injection is performed under sterile conditions, typically in an office or ambulatory surgery center (ASC). Covered conditions include wet age-related macular degeneration (AMD), diabetic macular edema (DME), central retinal vein occlusion (CRVO), and branch retinal vein occlusion (BRVO).

• Code range: Vitreous Procedures on the Posterior Segment, CPT 67005-67043
• Procedure type: Injection (non-surgical)
• Place of service: Office (11) or ambulatory surgical center (24)
• Bilateral: Must use RT/LT or -50 modifier when injecting both eyes
• Drug not included: The pharmacologic agent is billed separately via HCPCS J-code

Relative value units (RVUs) for CPT code 67028

RVUs determine Medicare reimbursement and are published annually by CMS. The FastRVU 2026 lookup tool confirms the following values for CPT 67028. Non-facility rates apply when the procedure is performed in an office; facility rates apply in an ASC or hospital outpatient department (HOPD).

The Practice Expense (PE) RVU gap between non-facility (2.07) and facility (0.18) settings is significant. Practices performing injections in their own office receive a substantially higher reimbursement than those using a hospital outpatient department. This makes in-office injection protocols financially advantageous where clinically appropriate.

2026 Medicare fee schedule for CPT code 67028

CMS publishes the annual Physician Fee Schedule via its fee schedule lookup tool. The 2026 national average conversion factor is approximately $32.35. Applying that to the RVUs above yields the following national average rates before geographic adjustment. Actual reimbursement varies by locality via the Geographic Practice Cost Index (GPCI). Use the electronic remittance advice from your MAC to confirm locality-adjusted payment after each remittance cycle.

These figures represent the procedure fee only. The drug administered (e.g., aflibercept, ranibizumab, bevacizumab) is reimbursed separately under the applicable HCPCS J-code, which often represents the largest portion of total reimbursement for anti-VEGF therapy. Practices should verify rates annually using the CMS fee schedule lookup, as the conversion factor adjusts each January 1.

Applicable modifiers for CPT code 67028

Modifier selection is where most 67028 claims encounter problems. Confirm insurance eligibility verification before each injection visit, then apply the correct modifiers at claim submission.

Billing CPT 67028 with an E/M code on the same day

WPS Government Health Administrators (a Medicare Administrative Contractor) confirms that a same-day evaluation and management service is separately billable when it is a distinct, medically necessary visit. The E/M code (typically 92012 for an established ophthalmology patient) must carry modifier -25 to signal that the evaluation was separate from the injection itself.

• Documentation must support two distinct services: the clinical decision-making behind the injection AND the evaluation findings
• A routine injection visit without new findings or a treatment decision does not justify a separate E/M
• The E/M note cannot simply say “patient here for injection” without documenting examination findings and a clinical assessment
• Modifier -25 is an OIG audit target: documentation must be airtight before appending it

Bilateral injection rules and RT/LT modifier application

Medicare requires -RT and -LT modifiers for bilateral intravitreal injections rather than modifier -50. Bill two line items: 67028-RT and 67028-LT. Medicare reimburses each at 100% of the allowed amount (unlike surgical procedures where bilateral reimbursement is reduced to 150% combined). Commercial payers may require modifier -50 on a single line. Verify each payer’s bilateral policy before claim submission, as incorrect modifier use is a frequent denial trigger.

ICD-10 diagnosis codes that pair with CPT code 67028

Medical necessity for CPT 67028 requires a covered ICD-10 diagnosis code. The CPT-to-ICD-10 crosswalk confirms the most commonly paired diagnoses. Payer-specific LCDs (Local Coverage Determinations) may restrict covered diagnoses further; always verify the applicable LCD for your MAC before submitting a claim.

Always code to the highest level of specificity. Laterality digits (1 = right eye, 2 = left eye, 3 = bilateral) are required for most retinal codes. Submitting a code without a laterality digit is a common clean claim failure.

HCPCS drug codes billed alongside CPT code 67028

CPT 67028 covers the injection procedure only. The pharmacologic agent is billed separately using an HCPCS Level II J-code. CMS requires both the procedure code and the drug code on the same claim for complete reimbursement. The following J-codes are the most commonly billed anti-VEGF agents in retina practices, per CMS Medicare Coverage Database article A53009.

Bevacizumab (Q2049) warrants special attention. Because it is not FDA-approved for ophthalmic use, Medicare coverage depends on each MAC’s LCD. Some MACs cover it with specific ICD-10 codes; others require prior authorization. Practices billing Q2049 should review their MAC’s LCD before assuming coverage.

Documentation requirements and medical necessity for CPT 67028

A complete 67028 claim requires documentation that satisfies both the procedure and the medical necessity requirements. For practices aiming to meet medical billing compliance standards, each injection encounter note should address the following elements. The superbill documentation generated at the point of care is the primary source for claim data.

• Diagnosis: ICD-10 code with laterality; clinical findings supporting the diagnosis (e.g., OCT imaging results, visual acuity measurements)
• Treatment plan: Rationale for continuing or initiating anti-VEGF therapy; treatment frequency and drug selection
• Drug and dose: Name of pharmacologic agent, concentration, dose administered, lot number, and route (intravitreal)
• Laterality: Specify right eye, left eye, or bilateral; must match the RT/LT modifier on the claim
• Informed consent: Signed consent documenting the patient’s understanding of risks (endophthalmitis, retinal detachment, increased IOP)
• Procedure note: Sterile technique, gauge needle used, post-injection IOP check, and any immediate complications
• Prior authorization: Documentation of payer approval number when required, particularly for newer agents or compounded bevacizumab

For same-day E/M billing, the documentation must clearly distinguish the evaluation from the injection itself. A note that only records vitals and “patient here for Eylea injection” does not support a separately billable E/M service. Ensure a complete ophthalmic examination with findings, assessment, and a distinct clinical decision is documented before appending modifier -25.

Practices using clean claim submission protocols catch these gaps before the claim leaves the practice.

Bundling rules and NCCI edits for CPT code 67028

The National Correct Coding Initiative (NCCI) publishes edit pairs that tell payers which codes are bundled and cannot be billed together without a supporting modifier. For CPT 67028, two bundling scenarios arise most frequently.

• 67028 + 67015 (vitreous tap): When a vitreous tap is performed at the same time as the injection, NCCI edits may bundle them. The AAO confirms that a vitreous tap performed to reduce IOP before the injection may be separately reportable with modifier -59 if the tap is a distinct procedural service with separate documentation. The tap must be medically necessary in its own right.
• 67028 + drug J-code: These are NOT bundled. The J-code must always appear on the same claim as 67028 to capture drug reimbursement. Omitting the J-code results in a zero-drug payment, which is not a denial but a missed charge.
• 67028 + 92012 (ophthalmology E/M): Bundled unless modifier -25 is on the E/M code. Without -25, the E/M is denied as included in the global period of the injection.

NCCI edit pairs are updated quarterly. Confirm current edits via the CMS NCCI edit tables before adding modifier -59 to any claim. Practices relying on outdated bundling guidance risk submitting claims with inappropriate unbundling, which is an OIG audit target.

Common billing errors and denial reasons for CPT code 67028

High-volume intravitreal injection practices see predictable denial patterns. Understanding denial codes in medical billing and the specific triggers for 67028 claims makes it possible to address them upstream rather than through appeals. Effective managing claim denials starts with identifying which errors recur most often.

How practice management software simplifies intravitreal injection billing

High-volume intravitreal injection practices benefit from automating the repetitive compliance checks that prevent 67028 denials. Manual processes across dozens of weekly injections create too many opportunities for a laterality error or a missing modifier to slip through to claim submission. Practices looking to improve their revenue cycle management for retina billing find that connecting clinical documentation directly to claim generation closes most gaps.

Pabau’s claims management software integrates clinical records, charge capture, modifier logic, and claim submission into a single workflow. Pabau connects directly to Claim.MD, a US clearinghouse that validates claims against payer rules before submission. Electronic claims via Claim.MD reach over 4,000 US payers, with real-time eligibility checks and electronic remittance advice (ERA) returned automatically after adjudication. For ophthalmology and retina practices with high injection volumes, this means fewer manual modifier checks, fewer denials, and faster payment cycles.

Reduce intravitreal injection claim denials with Pabau

Pabau connects clinical documentation, modifier logic, and claim submission in one workflow. See how retina and ophthalmology practices use Pabau and Claim.MD to reduce 67028 denials and speed up payment cycles.

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Conclusion

CPT code 67028 is one of the most frequently billed ophthalmology procedure codes in Medicare, and its denial rate reflects how many moving parts each claim involves: laterality modifiers, companion J-codes, payer-specific LCD restrictions, and modifier -25 documentation for same-day E/M services. Getting all of these right on every claim requires either rigorous manual processes or a system that enforces the rules at charge entry.

Pabau’s clearinghouse claim submission workflow, combined with built-in modifier prompts and ICD-10 linkage, helps ophthalmology practices catch 67028 errors before they reach the payer. To see how it works for your practice, book a demo with the Pabau team.

Continue your research

Need to understand what happens after a claim is submitted? Electronic remittance advice explains how ERA files work and how to read payer payment explanations.

Want to reduce your practice’s overall denial rate? Managing claim denials in healthcare covers the systematic approach retina and multi-specialty practices use to track and resolve denials.

Looking for a complete medical billing reference? Revenue cycle management outlines the full billing lifecycle from charge capture through final payment.

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