Report Materials
Why OIG Did This Audit
- For June 2022 through May 2023 (audit period), Medicare paid $313 million for 3.3 million injections of drugs into the eye (i.e., intravitreal injections). Medicare also paid $124 million for 1.4 million evaluation and management (E&M) services billed with modifier 25 and provided on the same day as intravitreal injections.
- Prior OIG audits of individual providers found high improper payment rates for E&M services provided on the same day as intravitreal injections.
- This audit identified Medicare Part B payments to providers for E&M services that were provided on the same day as intravitreal injections and that were at risk for noncompliance with Medicare requirements.
What OIG Found
- For 42 percent of intravitreal injections provided during our audit period, providers billed for E&M services provided on the same day as injections using modifier 25, which allowed the claims to bypass system edits that are designed to prevent improper payments.
- To test provider compliance with Medicare requirements, we reviewed documentation for 24 sampled E&M services and found that documentation for 22 services did not support the use of modifier 25.
- CMS paid for E&M services billed with modifier 25 and provided on the same day as intravitreal injections that were at risk for noncompliance because CMS’s internal controls were not adequate during our audit period to detect and prevent potentially improper payments. During our audit period, Medicare paid $124 million nationwide for these services.
What OIG Recommends
We made three recommendations to CMS, including that CMS update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to help providers understand appropriate use of modifier 25, and conduct medical reviews of E&M services and recover payments of up to $124 million for those services that CMS determines should not have been billed with modifier 25 during our audit period. The full recommendations are in the report.
CMS concurred with one recommendation and did not indicate concurrence or nonconcurrence with two recommendations. CMS also described actions it had taken or planned to take to address all of our recommendations.
25-A-09-066.01 to CMS - Open Unimplemented
Update expected on
11/26/2025
We recommend that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to help providers understand the appropriate use of modifier 25 (e.g., clarify the definition of a "significant and separately identifiable" E&M service and identify the circumstances that allow for an E&M service to be billed on the same date of service as an intravitreal injection).
25-A-09-066.02 to CMS - Open Unimplemented
Update expected on
11/26/2025
We recommend that the Centers for Medicare & Medicaid Services conduct medical reviews of E&M services that were provided on the same day as intravitreal injections to determine whether these payments were improper and, consistent with relevant laws and the agency's policies and procedures, recover payments of up to $123,955,176 for E&M services that CMS determines should not have been billed with modifier 25 during our audit period, and instruct those providers to refund to enrollees any coinsurance amounts that may have been incorrectly collected from them or from someone on their behalf.
25-A-09-066.03 to CMS - Open Unimplemented
Update expected on
11/26/2025
We recommend that the Centers for Medicare & Medicaid Services provide more education to providers on billing E&M services provided on the same day as intravitreal injections and the appropriate use of modifier 25 to help prevent improper payments for those services. For example, CMS could: (1) emphasize that the decision to perform an intravitreal injection is part of the minor surgical procedure and a separate E&M service should not be billed for that work; (2) provide a clear definition of a "significant and separately identifiable" E&M service that is "above and beyond" the usual care associated with an intravitreal injection; and (3) provide examples of E&M services that would be considered significant and separately identifiable and above and beyond the usual care associated with an intravitreal injection.
View in Recommendation Tracker
Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.