Does 67228 require prior authorization?

No, 67228 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 67228?

Medicare facility rate: $253.85. Non-facility rate: $341.02. Work RVU: 4.28.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

4.28

Facility

$253.85

Non-Facility

$341.02

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
The diagnosis code(s) submitted must best describe the patient's condition for which the service was performed and must be a valid ICD-10-CM code.
Use modifiers LT/RT to indicate the operative site and use modifier -50 if both eyes are treated on the same day/session.

Panretinal (scatter) laser photocoagulation (PRP) is covered when medically necessary and supported by the Local Coverage Determination (LCD) and the patient's medical record.
Panretinal (scatter) laser photocoagulation (CPT 67228) is payable under Medicare Part B when performed in office (POS 11), inpatient hospital (POS 21), outpatient hospital (POS 22), emergency room hospital (POS 23), ambulatory surgical center (POS 24), or independent clinic (POS 49).
Panretinal laser services may be billed to the Part A MAC for inpatient or hospital outpatient claims when the appropriate principal/admitting/outpatient diagnosis codes and hospital billing requirements are met.
Panretinal laser photocoagulation is indicated for treatment or management of proliferative diabetic retinopathy.
Panretinal laser photocoagulation is indicated for treatment or management of pre-proliferative diabetic retinopathy.
Panretinal laser photocoagulation is indicated for severe diabetic macular edema when associated with pre-proliferative retinopathy.

A56550 — Billing and Coding: Panretinal (Scatter) Laser Photocoagulation

J06

L33628 — Panretinal (Scatter) Laser Photocoagulation

J06

A56594 — Billing and Coding: Panretinal (Scatter) Laser Photocoagulation

L34064 — Panretinal (Scatter) Laser Photocoagulation

Ask Verity about documentation requirements, denial risks, or coverage in your state.