Operative Notes for Intravitreal Injections – Ophthalmic Professional

Proper operative note documents for minor retinal procedures—specifically, intravitreal injections, are necessary. Once the need for an injection is determined, the technician or medical assistant is charged with pulling a “standard” operative note. It is crucial this document contains all relevant information.

Intravitreal injection (CPT code 67028) is the most common Medicare procedure in ophthalmology. There are a half dozen or more drugs used to treat a great many conditions. If we deal with only the more common of these, there are only a handful of FDA-approved on-label indications and they vary by specific drug. The newest drug is for use with vitreomacular traction, but only one has that approval. As a result, we have multiple drugs and conditions being treated, but most of the time we may be able to use a more standard document.

For a full checklist, see the complete article (link below).

This article was published in Ophthalmic Professional’s Coding column, and written by Corcoran’s Senior Consultant, Paul Larson, COE. To view the entire article in Ophthalmic Professional, click on the link below:


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