Injection Claims in Two Parts
An intravitreal injection claim pairs the procedure line with a drug line. Both must name the same eye, and the drug line must carry the right code, units and waste modifier. The table below shows the drugs we bill most.
| Drug | HCPCS | Billing unit | Typical dose in units |
|---|---|---|---|
| Aflibercept (Eylea) | J0178 | 1 mg | 2 mg = 2 units |
| Aflibercept HD (Eylea HD) | J0177 | 1 mg | 8 mg = 8 units |
| Faricimab (Vabysmo) | J2777 | 0.1 mg | 6 mg = 60 units |
| Ranibizumab (Lucentis) | J2778 | 0.1 mg | 0.5 mg = 5 units |
| Pegcetacoplan (Syfovre) | J2781 | 1 mg | 15 mg = 15 units |
| Avacincaptad pegol (Izervay) | J2782 | 0.1 mg | 2 mg = 20 units |
Bevacizumab (Avastin) used off-label is billed the way each Medicare contractor or payer instructs, and biosimilars have their own Q codes. We confirm the code, NDC and units against the vial used, not the one scheduled.
Retina Imaging and Testing Claims in the USA
Retina practices in the USA run imaging at most visits, and each test has frequency limits and bundling rules. We code these tests and check them before submission.
- OCT of the retina (92134), which is not billed with optic nerve OCT (92133) on the same day
- Fluorescein angiography (92235), indocyanine green angiography (92240) or both together (92242)
- Fundus photography (92250), which has bundling edits with some imaging
- Extended ophthalmoscopy (92201, 92202) with the required drawing
- Ophthalmic B-scan ultrasound (76512)
Prior Authorization and Step Therapy for Retina Drugs
Many commercial, Medicare Advantage and Medicaid managed care plans require prior authorization for anti-VEGF drugs. Some require step therapy, where bevacizumab has to fail before aflibercept or faricimab is approved. Our prior authorization team submits the diagnosis, imaging findings and treatment history for each eye, then tracks each approval by drug, eye, number of injections and end date. Your schedulers see a warning before the last approved injection is used.
Modifier 25 Audit Risk on Retina Injection Days
A 2025 HHS OIG report found that 42% of intravitreal injections were billed with a same-day E/M and modifier 25, and 22 of 24 sampled visits did not meet Medicare requirements. Medicare paid $124 million for those visits during the audit period, and a supplemental medical review contractor has reviewed ophthalmology E/M claims billed with modifier 25 on injection days.
The injection code already includes the evaluation that leads to the injection. A separate visit needs a separate problem, such as a new complaint in the other eye or management of a different condition, with its own assessment and plan. Our coding team reviews every injection-day modifier 25 before the claim goes out.
Retinal Laser and Surgical Billing
Retina procedures carry different global periods, which change how follow-up visits are billed.
| Procedure | Common codes | What we watch |
|---|---|---|
| Intravitreal injection | 67028 | 0-day global, drug line, bilateral rule |
| Focal or panretinal laser | 67210, 67228 | Laterality, repeat sessions within the global period |
| Retinal detachment repair | 67108, 67113 | 90-day global, return to the OR with modifier 78 |
| Vitrectomy | 67036 to 67043 | Correct code for membrane peel or laser, facility claim split |
When surgery happens in an ASC, the facility claim is separate. See ophthalmic ASC billing.
Drug-Level Reporting for Retina Billing
Retina revenue depends on drug margins, so our monthly report shows drug payments by payer against acquisition cost, injection volume by drug and denial rates on drug lines. Drug claims that deny are worked first by our denial management team because of their value. A free billing audit shows how your injection claims are paying today.