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Official Description

Retrobulbar injection; medication (separate procedure, does not include supply of medication)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 67500 involves a retrobulbar injection, which is a targeted injection of medication into the retrobulbar space, the area behind the eyeball. This procedure is classified as a separate procedure, meaning it does not include the supply of the medication used during the injection. The retrobulbar region is significant in ophthalmology as it allows for the delivery of medications directly to the area surrounding the optic nerve and other structures within the eye, which can be crucial for treating various ocular conditions. The injection is typically performed under sterile conditions, and local anesthesia may be administered to minimize discomfort for the patient. The technique requires precision, as the needle must be carefully inserted to avoid damaging surrounding blood vessels or vital structures within the eye. This procedure is often utilized in the management of conditions such as glaucoma, ocular inflammation, or for providing anesthesia during eye surgeries.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The retrobulbar injection procedure is indicated for several specific conditions and therapeutic purposes, including:

  • Ocular Inflammation This procedure may be performed to deliver anti-inflammatory medications directly to the retrobulbar space to manage conditions such as uveitis or other inflammatory disorders of the eye.
  • Glaucoma Management Retrobulbar injections can be utilized to administer medications that lower intraocular pressure in patients with glaucoma.
  • Preoperative Anesthesia This injection is often indicated for providing anesthesia prior to ocular surgeries, ensuring patient comfort during procedures.
  • Pain Management The procedure may be indicated for the management of pain associated with various ocular conditions or post-surgical recovery.

2. Procedure

The retrobulbar injection procedure involves several critical steps to ensure accuracy and safety:

  • Step 1: Preparation The skin over the lateral aspect of the lower eyelid is thoroughly cleansed to maintain a sterile environment. A local anesthetic may be administered to minimize discomfort during the procedure.
  • Step 2: Needle Insertion The clinician inserts the needle through the skin of the eyelid, slightly lateral to the midline of the eye. This precise location is chosen to access the retrobulbar space effectively.
  • Step 3: Needle Direction The needle is inserted straight down through the septum, which is the fibrous tissue separating the eyelid from the orbit. Once the needle reaches the appropriate depth, it is redirected upward to position it within the free space of the retrobulbar region.
  • Step 4: Aspiration The clinician withdraws the plunger of the syringe to aspirate, ensuring that the needle is not located within a blood vessel or any vital structure of the eye. This step is crucial for patient safety.
  • Step 5: Injection Once confirmed that the needle is in the correct location, the medication or alcohol mixture is injected into the retrobulbar space. This allows for targeted delivery of the therapeutic agent.
  • Step 6: Withdrawal and Pressure Application After the injection, the needle is carefully withdrawn, and gentle pressure is applied over the injection site to minimize bleeding and promote healing.

3. Post-Procedure

After the retrobulbar injection, patients are typically monitored for any immediate adverse reactions. It is important to observe for signs of complications such as bleeding, infection, or inadvertent damage to surrounding structures. Patients may experience temporary discomfort or bruising at the injection site. Instructions for post-procedure care may include avoiding strenuous activities and monitoring for any unusual symptoms. Follow-up appointments may be scheduled to assess the effectiveness of the treatment and to manage any ongoing care needs.

Short Descr INJECT/TREAT EYE SOCKET
Medium Descr RETROBULBAR INJECTION MEDICATION SPX
Long Descr Retrobulbar injection; medication (separate procedure, does not include supply of medication)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P4E - Eye procedure - other
MUE 1
CCS Clinical Classification 21 - Other extraocular muscle and orbit therapeutic procedures
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
RT Right side (used to identify procedures performed on the right side of the body)
LT Left side (used to identify procedures performed on the left side of the body)
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
GX Notice of liability issued, voluntary under payer policy
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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