Ophthalmology and Optometry Coding Alert

Question: One of our patients is having Eylea injections, but the provider is using a sample. Can our office still bill for the adminis­tration of the drug?

AAPC Forum Participant

Answer: According to the American Academy of Ophthalmology (AAO), even though there is no charge associated with a drug, and you expect no payment for it from the payer, you will still need to submit the HCPCS drug code on the claim in order to get paid for the drug administration. How you do it will differ from payer to payer, however.

For Medicare Part B and payers who allow zero-dollar charges, you should submit the claim with two units of the appropriate J code for the drug (for Eylea, you would use J0178 (Injection, aflibercept, 1 mg)) and a $0.00 charge

For payers who do not allow zero-dollar charges, you should submit the claim with a $0.01 charge for the drug along with a note in item 9 stating the Eylea provided was a sample.

This will then allow you to receive reimbursement for the injection administration, which you will bill using 67028 (Intravitreal injection of a pharmacologic agent (separate procedure)) with modifier LT (Left side), RT (Right side), or 50 (Bilateral procedure) as appropriate.