CPT 67028 is the administration code for an intravitreal injection of a pharmacologic agent — the procedural work of placing a retinal drug (Eylea, Lucentis, Vabysmo, Beovu, Eylea HD, ranibizumab biosimilars, or off-label Avastin) into the vitreous cavity. It is billed once per eye per encounter, on a separate line from the drug J/Q-code, and every line must carry RT, LT, or modifier 50. A 67028 claim without a laterality modifier is rejected automatically as incomplete — this is the single largest source of 67028 denials.
67028 is defined in the AMA Current Procedural Terminology (CPT) manual under the Eye and Ocular Adnexa surgery chapter, with the long descriptor “Intravitreal injection of a pharmacologic agent (separate procedure).” The “separate procedure” designation matters: 67028 is bundled into more comprehensive intraocular procedures (e.g., vitrectomy) performed at the same operative session and is billable independently only when it is the primary or stand-alone service. The code is unilateral by construction; bilateral injections require modifier 50 (or RT/LT on different dates of service).
Coding guidance for 67028 is maintained by the American Academy of Ophthalmology (AAO) through its annual coding updates and the OphthalmicHealth coding products, and enforcement is driven by Local Coverage Determinations (LCDs) published by each Medicare Administrative Contractor for intravitreal therapy. The Medicare NCCI Procedure-to-Procedure (PTP) edit table identifies the codes that bundle with 67028; OCT imaging (92133/92134) is the most clinically relevant edit pair and is MAC-LCD-specific. Commercial payers have largely aligned with the CMS framework for 67028, with policy bulletins from UnitedHealthcare, Aetna, Cigna, and Humana referencing the same laterality and bundling rules.
The volume case for 67028 is the wet AMD / DME / RVO patient on a maintenance injection schedule. A typical cadence is monthly induction for three injections followed by Q8W or treat-and-extend, often staggered between eyes by one to two weeks to reduce simultaneous post-injection inflammation. Each staggered visit is a single-eye encounter (RT or LT). The subset of patients injected bilaterally at the same visit is where the modifier 50 versus RT+LT decision matters most — the wrong construction underpays by roughly 25% versus the correct bilateral rule. The full anatomic-modifier decision logic is covered on the eye anatomic modifier reference.
The top operational failure mode for 67028 is omitting laterality. The drug line and the administration line each require their own anatomic modifier, and missing the modifier from either line denies the corresponding service. Detailed RT/LT/modifier 50/E1–E4 logic lives on the eye-anatomic modifier reference page.
All major payers align with the CMS framework for 67028: laterality required, drug code paired on a separate line, bundling per NCCI PTP edits, bilateral via modifier 50. Variation shows up in same-day OCT bundling, off-label Avastin documentation, and site-of-care steering. Medicare Advantage plans frequently mirror commercial site-of-care rules and may steer retinal injections to ASC settings to reduce facility cost.
| Payer | 67028 laterality required? | Notes |
|---|---|---|
| Medicare (Part B) | Yes — rejects without RT, LT, or modifier 50 | Source-of-truth payer. MAC LCDs for intravitreal therapy publish the covered ICD-10 list, the OCT bundling posture, and the off-label Avastin documentation requirement. Bilateral same-day pays 150% per the Medicare Physician Fee Schedule bilateral payment rule when modifier 50 is used. NCCI PTP edits identify codes that bundle with 67028. |
| UnitedHealthcare | Yes | Aligns with CMS at adjudication. UHC commercial medical-policy bulletins for anti-VEGF therapy reference the same LCD-style covered-indication list. OptumRx infused-meds management approval needs to reflect the drug, dose, and laterality. UHC Medicare Advantage may apply additional site-of-care review for HOPD-billed retinal injections. |
| Aetna (CVS Health) | Yes | Aligns with CMS. Aetna's anti-VEGF medical-policy bulletins explicitly require laterality on both the drug line and the 67028 line. Same-day OCT bundling follows CMS LCD posture by region. CVS Specialty distribution does not change the medical-claim billing pattern for buy-and-bill practices. |
| Cigna / Express Scripts | Yes | Aligns with CMS. Accredo specialty-pharmacy dispense-and-deliver model can replace buy-and-bill for some commercial retinal patients; in white-bag scenarios the practice still bills 67028 with laterality for the administration. Cigna commercial medical-policy bulletins reference the AAO coding guidance for intravitreal injection. |
| Humana | Yes | MA-heavy book follows CMS LCD posture by region. CenterWell Specialty white-bag program shifts the drug-supply economics but not the 67028 admin-billing requirement. Humana commercial-PPO has the same laterality rule. Some Humana MA plans require prior auth for repeat anti-VEGF therapy beyond a defined number of injections per year. |
| Denial pattern | What it means | Fix / appeal language |
|---|---|---|
| Missing RT/LT/50 on 67028 (CARC 4 / RARC M51 or similar) | 67028 submitted without a laterality modifier. Payer reads the claim as incomplete because the procedure is unilateral by construction and the eye is not identified. | Resubmit with RT, LT, or modifier 50 appended to the 67028 line, and confirm the drug J-code line carries matching laterality. Appeal language: “Per AMA CPT and AAO coding guidance, CPT 67028 is unilateral and requires an anatomic modifier identifying laterality. The corrected claim appends [RT/LT/50] to both the drug line and the 67028 administration line.” See the eye-anatomic modifier reference for the full decision tree. |
| 67028-RT + 67028-LT on two lines (bilateral construction error) | Bilateral same-day injection billed as two unilateral lines instead of one line with modifier 50. Triggers either a duplicate-line edit or pays 100% + 50% = 150% by the multiple-procedure formula rather than the bilateral rule design. | Resubmit with a single 67028 line carrying modifier 50. Appeal language: “The bilateral intravitreal injection performed on [date] should be reported as a single line of 67028 with modifier 50 per the Medicare Physician Fee Schedule bilateral payment rule and AAO coding guidance, not as two unilateral lines. The corrected claim consolidates to one 67028-50 line.” |
| 67028 + OCT 92133/92134 same-day bundled (NCCI / LCD edit) | OCT line denied as bundled into 67028 per the local MAC LCD or NCCI PTP edit. Some MACs bundle routine OCT into 67028 on maintenance visits and pay separately only when imaging supports a treatment-decision change. | Confirm the LCD posture in your jurisdiction. If the imaging supported a treatment decision (drug switch, reactivation, fluid recurrence), resubmit the OCT line with modifier 59 or XU (per NCCI guidance) and chart documentation supporting the separate clinical purpose. If routine, accept the bundle and stop billing OCT same-day on routine maintenance encounters in this MAC region. |
| 67028 billed without paired drug J-code line | Administration code submitted but no corresponding J/Q-code line on the same claim for the drug supplied. Payer reads as a mismatch: the practice billed for the work but not the agent injected. | Resubmit a corrected claim with both lines: the drug J/Q-code (J0178 Eylea, J2778 Lucentis, J2777 Vabysmo, J0179 Beovu, J0177 Eylea HD, Q5128 Cimerli, Q5124 Byooviz, J9035 Avastin) and the 67028 admin line, each with matching laterality. Appeal language: “An intravitreal injection encounter generates two distinct billable services: the drug supplied (J/Q-code) and the procedural administration (67028). The corrected claim includes both lines with matching anatomic modifiers.” |
| Off-label J9035 Avastin denied (no GA / no ABN) | Off-label intravitreal bevacizumab denied for coverage. Some MACs require modifier GA on the drug line and a signed ABN retained in the chart as the documentation chain supporting off-label use. | Resubmit with modifier GA appended to the J9035 line. Attach (or have on file) the signed ABN and a chart note referencing compendia support for off-label intravitreal bevacizumab. Appeal language: “Off-label intravitreal bevacizumab is covered under [compendia citation]. The corrected claim appends modifier GA reflecting the waiver-of-liability statement issued; the signed ABN is retained per CMS documentation requirements and is available on request.” |
| Diagnosis-LCD mismatch | 67028 line denied because the ICD-10 code submitted is not on the MAC LCD's covered-indication list for intravitreal anti-VEGF therapy. | Review the LCD covered-indication list (commonly H35.32x wet AMD, H35.81 with diabetic retinopathy codes for DME, H34.83x BRVO, H34.81x CRVO, H44.2x myopic CNV). Resubmit with the correct specific ICD-10 code if the diagnosis supports coverage and was miscoded. If the actual indication is not covered, the service is non-covered and may require ABN handling. |
67028 is the administration code paired with every intravitreal pharmacologic agent: Eylea (J0178), Eylea HD (J0177), Lucentis (J2778), Vabysmo (J2777), Beovu (J0179), Cimerli (Q5128, ranibizumab biosimilar), Byooviz (Q5124, ranibizumab biosimilar), and off-label Avastin (J9035). Each encounter generates two billable services: the drug supplied (the J-code or Q-code) and the procedural injection work (67028). Both lines carry the laterality modifier independently.
For a bilateral same-day intravitreal injection, the correct construction under the Medicare Physician Fee Schedule and AAO coding guidance is one line of 67028 with modifier 50 appended. That pays 150% of the unilateral fee. Billing 67028-RT and 67028-LT on two separate lines is a common error that triggers either a duplicate-line edit or an underpayment versus the bilateral rule. The 150% rule is the payment design choice CMS made; honor it by using modifier 50.
Same-day OCT is billable separately in many scenarios but the rule is MAC- and LCD-specific. Some MACs bundle OCT into 67028 on routine maintenance visits and pay separately only when the imaging supports a treatment-decision change (e.g., reactivation, fluid recurrence, switch in drug). Other MACs pay both routinely. Check the LCD for retinal imaging in your jurisdiction. When OCT is billed same-day, the imaging line typically does not require a modifier; the E/M (if billed) carries modifier 25.
Yes, when the E/M is significant, separately identifiable, and above and beyond the usual pre- and post-injection work — for example, an initial wet AMD evaluation, a switch in therapy, or evaluation of a new clinical problem. Append modifier 25 to the E/M line. Routine pre-injection examinations are bundled into the global of 67028 and should not be billed as a separate E/M. Practices that habitually bill E/M with 67028 on maintenance visits are a top audit target.
Avastin (bevacizumab, J9035) is FDA-approved for oncology indications but not for intravitreal use; ophthalmic use is widespread, evidence-supported, and covered by Medicare and most commercial payers under compendia-based off-label coverage. Some MACs require modifier GA (waiver of liability statement issued, ABN on file) when the off-label use creates any risk of non-coverage at adjudication. Practice-level policy varies; check the LCD and the payer medical-policy bulletin. The ABN itself is signed by the patient before injection and retained in the chart.
Most intravitreal injections are performed in an office-based ophthalmology practice (POS 11), where the practice buy-and-bills the drug and bills 67028 for the administration. Hospital outpatient departments (POS 22) bill the drug under OPPS and 67028 under the Outpatient Prospective Payment System; the professional component is billed separately by the physician. Some Medicare Advantage plans and commercial payers have started steering retinal injections to ASC settings to reduce facility cost; verify site-of-care policy with each payer's medical policy.
Different-day injections to opposite eyes are billed as two separate unilateral encounters. Each date of service has its own claim line: 67028-RT on the right-eye date plus the J-code-RT for the drug; 67028-LT on the left-eye date plus the J-code-LT. Modifier 50 does not apply across dates of service. The staggered-injection pattern is common for wet AMD patients to reduce simultaneous post-injection inflammation; each visit is paid the full unilateral rate.
No. The CPT descriptor for 67028 is specifically “intravitreal injection of a pharmacologic agent.” Injection of a non-pharmacologic substance, intraocular foreign body removal, or diagnostic vitreous tap procedures use different CPT codes (e.g., 67005 for partial removal of vitreous, 67015 for aspiration of fluid). Read the CPT descriptor against the procedure performed and the indication; do not default to 67028 simply because the route was intravitreal.
All sources are publicly available federal publications, AMA-licensed coding references, or paraphrased from trade-association and payer educational materials. The methodology by which we resolve source disagreements is described in the Methodology.