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  • Retina Ask the Expert

    Intravitreal Injection for Geographic Atrophy


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    How should we code for an intravitreal injection with a new drug for geographic atrophy (GA) (e.g., Syfovre), and are there any initial challenges with payer coverage? 

    Answer:
    Report Syfovre with a not otherwise classified (NOC) Healthcare Common Procedure Coding System (HCPCS) code (e.g. J3490) and link to the appropriate ICD-10 code for nonexudative age-related macular degeneration, along with the injection, CPT code 67028 and anatomical modifier (-RT, -LT, -50).

    Because it is a novel treatment, payer policies initially will not include treatment of dry AMD. Consider this to prepare for an appeal if appropriate:
    • Reporting NOC HCPCS codes require the medication name and dosage in item 19 or electronic equivalent of the CMS-1500 claim form. Confirm you have a clean claim prior to submission, and review the Academy webpage Coding for Injectable Drugs for guidance. 
    • Claims may be denied initially due to the reported ICD-10 code for dry AMD.
    • CPT code 67028 has a medically unlikely edit (MUE) of 1. If two injections are performed the same day — one treatment for geographic atrophy and a second with an anti-VEGF — due to the MUE, only one injection can be paid. Report 67028 once with 1 unit.
    • If an anti-VEGF injection is performed, and within the next 28 days, an injection for GA is performed in the same eye, the payer may deny the claim. Although the GA treatment is not subject to the “28-day rule,” payer claim edits may initially deny.

    Promptly identifying the reason for denial and submitting a comprehensive appeal letter will contribute to timely reimbursement. For more on retina coding, visit aao.org/retinapm.