Basics of CPT code 67516
A new code (67516) has been added to the CPT 2024 code set within the Eye and Ocular Adnexa subsection of the Surgery section to report suprachoroidal injection of a pharmacologic agent. As a result of the changes in this subsection, Category III code 0465T, Suprachoroidal injection of a pharmacologic agent (does not include supply of medication), and its corresponding parenthetical notes will be deleted effective January 1, 2024. A cross-reference parenthetical note has been established to inform users of the deleted code and to instruct how to report the new code when a suprachoroidal injection of a pharmacologic agent is performed. This article provides information on the intended use of code 67516.sa4cazC
Description of CPT code 67516
Eye and Ocular Adnexa
Orbit
67515 Injection of medication or other substances into Tenon’s capsule
(For subconjunctival injection, use 68200)
67516 Suprachoroidal space injection of pharmacologic agent (separate procedure)
(Report medication separately)
Code 67516 describes the administration of a drug into the suprachoroidal space between the sclera and choroid, which concentrates the drug near the posterior segment of the eye. This limits exposure of the drug to the anterior segment of the eye. The supply of the medication may be reported separately, as directed in the instructional parenthetical note following the code. Note that code 67516 is identified as a separate procedure; therefore, it may not be reported in addition to a more complex procedure that includes suprachoroidal injection.
The following clinical example reflects a typical clinical scenario for which this new code would be appropriately reported.
Clinical Example (cpt code 67516)
A 45-year-old female with macular edema associated with non-infectious uveitis in the right eye is referred for suprachoroidal space injection of a medication.
Description of Procedure (cpt code 67516)
Connect the hub adapter for the needle to the vial of medication to be administered. Draw the medication up into the suprachoroidal injector. Then exchange the adapter for the 900-micron suprachoroidal needle. Remove any residual air bubbles and express any excess medication. Use a caliper to measure 4 mm posterior to the limbus and mark the injection site. Place the injector perpendicular to the sclera. Apply pressure to dimple the conjunctiva and underlying sclera. While gentle pressure is applied to the plunger, manipulate the injector to maintain perpendicularity and pressure until loss of resistance is noted.
If no loss of resistance is achieved, increase pressure dimpling the sclera while continuously repositioning the injector to maintain perpendicularity and find the suprachoroidal space. If there is no success with the 900-micron needle, remove it and replace it with an 1100-micron needle and repeat the same steps. Once loss of resistance is achieved, continue a slow push until all the medication has been administered into the suprachoroidal space. Then place a cotton swab over the injection site and maintain pressure to prevent reflux of the medication. Rinse patient’s eye with saline solution to remove any residual povidone-iodine solution. Remove the lid speculum.
