Print Table

Hospital Outpatient Department (HOPD):
Coding And Billing For JETREA®

The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is not intended to be comprehensive. It is the sole responsibility of the provider to select proper coding for rendered products or services and to ensure the accuracy of all claims used in seeking reimbursement. Neither ThromboGenics® nor JETREA CARE® can guarantee payment of any claim.

Classification Category Coding System Code Description Notes
Diagnosis ICD-9-CM1 379.27* Vitreomacular Adhesion
  • Effective as of
    October, 2011
Right Eye
Left Eye
  • Effective
    October 1, 2015
Administration Procedure CPT Code 67028 Intravitreal injection of a pharmacologic agent3
  • CPT modifiers to document
    affected eye3
    • RT – Right side
    • LT – Left side
Drug Code HCPCS J7316 Injection,
0.125 mg4
  • Reported as
    3 units for a
    single-use vial
C9298§ Injection, Ocriplasmin,
0.125 mg5
  • Reported as
    3 units for a
    single-use vial
NDC 24856-0002-01 One single-use vial of JETREA6
  • 11-digit format is generally preferred for medical claims
    (10-digit format is 24856-002-01)
*Excludes traction detachment with vitreoretinal organization (361.81).
†Effective as of October 1, 2015
Effective as of January 1, 2014
§Effective as of April 1, 20135
CPT, Current Procedural Terminology; HCPCS, Healthcare Common Procedure Coding System; ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; NDC, National Drug Code.
Utilize JETREA CARE® to Investigate Specific Payer
Coding and Billing Requirements
1. 2013 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for Physicians, Volumes 1 & 2. 2012 Elsevier Saunders. 2. National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Available at: Accessed July 14, 2015. 3. Ophthalmology Management. Coding for intravitreal injections. Available at: Accessed July 14, 2015. 4. HIPAA Space. HCPCS 2015 code: J7316: injection, ocriplasmin, 0.125 mg. Available at: Accessed July 14, 2015. 5. CMS Manual System Transmission R2664CP March 1, 2013. 6. HIPAA Space. 24856-001-00: JETREA. Available at: Accessed July 14, 2015.

09/2017 OCRVMA0316


JETREA (ocriplasmin) injection, for Intravitreal Injection, 1.25 mg/mL is a proteolytic enzyme indicated for the treatment of
symptomatic vitreomacular adhesion.

Important Safety Information

Warnings and Precautions

  • A decrease of ≥ 3 lines of best-corrected visual acuity (BCVA) was experienced by 5.6% of patients treated with JETREA and 3.2% of patients treated with vehicle in the controlled trials. The majority of these decreases in vision were due to progression of the condition with traction and many required surgical intervention. Patients should be monitored appropriately.
  • Intravitreal injections are associated with intraocular inflammation/infection, intraocular hemorrhage and increased intraocular pressure (IOP). Patients should be monitored and instructed to report any symptoms without delay. In the controlled trials, intraocular inflammation occurred in 7.1% of patients injected with JETREA vs 3.7% of patients injected with vehicle. Most of the post-injection intraocular inflammation events were mild and transient. If the contralateral eye requires treatment with JETREA, it is not recommended within 7 days of the initial injection in order to monitor the post-injection course in the injected eye.
  • Potential for lens subluxation.
  • In the controlled trials, the incidence of retinal detachment was 0.9% in the JETREA group and 1.6% in the vehicle group, while the incidence of retinal tear (without detachment) was 1.1% in the JETREA group and 2.7% in the vehicle group. Most of these events occurred during or after vitrectomy in both groups.
  • Dyschromatopsia (generally described as yellowish vision) was reported in 2% of all patients injected with JETREA. In approximately half of these dyschromatopsia cases there were also electroretinographic (ERG) changes reported (a- and b-wave amplitude decrease).

Adverse Reactions

  • The most commonly reported reactions (≥ 5%) in patients treated with JETREA were vitreous floaters, conjunctival hemorrhage, eye pain, photopsia, blurred vision, macular hole, reduced visual acuity, visual impairment, and retinal edema.

Please see full Prescribing Information for JETREA.

You are encouraged to report side effects of prescription drugs to the FDA. Visit MedWatch or call 1-800-FDA-1088. You may also report side effects of JETREA online directly to ThromboGenics by clicking here if you are a Health Care Professional.

For medical information inquiries, or to report an adverse event or product-related complaint, please call 1-855-253-7396 or email