Medicare Reimbursement for Intravitreal Injections

Ophthalmologists, most often retina specialists, utilize intravitreal injections to treat a number of retinal conditions.  Many of the diseases are severe, with poor prognoses and limited treatment options.  They include:  exudative age-related macular degeneration (wet AMD), clinically significant macular edema (CSME), central retinal vein occlusion (CRVO), retinal detachment (RD), endophthalmitis, fungal infections, vitreous hemorrhage, and cytomegalovirus (CMV) retinitis.

This FAQ addresses the following:

  1. What conditions are treated with intravitreal injections?
  2. What considerations affect coding and reimbursement of intravitreal injections?
  3. Will insurance cover an off-label, investigational or experimental use of medication delivered by intravitreal injection?
  4. What CPT codes describe intravitreal injections?
  5. Both codes are designated “separate procedure”.  What is the significance of this designation?
  6. May I be reimbursed for paracentesis immediately prior to an intravitreal injection?
  7. Is this procedure reimbursed during the postoperative period of another surgery?
  8. Does the place of service affect physician reimbursement for intravitreal injections?
  9. What is the reimbursement for these procedures?
  10. How is the injected substance reimbursed?
  11. How frequently are intravitreal injections performed?

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