Modifier –25 Under the Microscope

Removing some of the mystery behind the use of this often-used CPT code.

By George A. Williams, MD
 

The growth of intravitreal drug therapy for the treatment of retinal diseases over the past decade has been unprecedented. The number of intravitreal injections performed annually in the United States rose from less than 3000 in 1999 to more than 1 million in 2008,1 and it is estimated that more than 7 million intravitreal injections will be performed in the United States in 2017. The therapeutic benefit of these treatments is both inarguable and profound. Correct coding and billing of intravitreal injection (CPT code 67028) is critical to optimal practice management.

BILLING FOR E/M SERVICES

CPT code 67028 has a zero-day global period, meaning it is considered a minor surgical procedure by Medicare. As a general rule, evaluation and management (E/M) services performed on the same day as a minor surgical procedure are bundled into the procedure. However, when there is significant, separately identifiable work, an E/M service may be billed using modifier –25.

The CPT definition of modifier –25 is ”Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Its use is indicated when a patient’s condition requires a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service being reported.

For ophthalmologists, it is important to note that the eye codes (92002, 92004, 92012, 92014) are reportable E/M services. The E/M service may be prompted by the symptom or condition for which the procedure or service was provided. Therefore, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding modifier –25 to the appropriate level of E/M service.

MODIFIER –25 AND INTRAVITREAL INJECTIONS

Based on the definition of modifier –25, the American Academy of Ophthalmology (AAO) has repeatedly published guidelines on the correct use of this modifier for intravitreal injections.2 These guidelines have been presented to the Centers for Medicare and Medicaid Services (CMS), both in writing and at meetings, with the specific request that if CMS disagrees with these guidelines it should inform the AAO. To date, CMS has not notified the AAO of any disagreement.

The National Correct Coding Initiative (NCCI) is responsible for determining correct coding, particularly for the role of combining or bundling procedures when appropriate. When the NCCI determines that there is no scenario in which an E/M service can be used with another procedure or service, an unbreakable bundle (category 0) is created. This means that these two codes are always bundled and that payment for the E/M service is always inappropriate. When NCCI determines that there are valid clinical reasons to allow an E/M service to be used on the same day as a minor surgical procedure, it allows the use of the appropriate modifier (category 1) with appropriate supporting documentation. Currently, NCCI allows the use of modifier –25 for an E/M service provided on the same day as an intravitreal injection.

It is important to note that CMS is fully aware that E/M services are billed with intravitreal injections more than 50% of the time. This fact is accounted for in the valuation of CPT code 67028. Given the above, when is it correct to use modifier –25 with an intravitreal injection? The clinical scenarios on the next page provide some clarification.

There are two primary factors to consider when determining whether an E/M service should be billed with modifier –25.

Factor No. 1: Determining Injection Need

If the examination is performed to determine the need for an injection, use of modifier –25 for an E/M service is appropriate. By contrast, if the examination is performed to confirm the need for a previously determined injection, use of the modifier for an E/M service is inappropriate.

Factor No. 2: Examining the Fellow Eye

It is important to remember that age-related macular degeneration (AMD) and diabetic retinopathy are bilateral, chronic diseases. It is good medical practice to examine the fellow eye on a regular basis. How frequently such examinations should occur and at what level is a matter of clinical judgment and depends on the state of disease in each patient. When the fellow eye is examined, an E/M service is often appropriate, assuming medical necessity.

NOT-SO-SIMPLY STATED

The use of modifier –25 in conjunction with intravitreal injection is often, but not always, appropriate and correct coding that recognizes the performance of a significant, separately identifiable service when there is medical necessity.


1. Campbell RJ, Bronskill SE, Bell CM, Paterson JM, Whitehead M, Gill SS. Rapid expansion of intravitreal drug injection procedures, 2000 to 2008: a population-based analysis. Arch Ophthalmol. 2010;128(3):359-362.

2. Vicchrilli S. American Academy of Ophthalmology. Modifier –25 revisited. www.aao.org/eyenet/article/modifier-25-revisited. October 2017. Accessed October 24, 2017.
 

Section Editor George A. Williams, MD
• chair, department of ophthalmology, William Beaumont Hospital, Royal Oak, Mich.; professor and chair of ophthalmology, Oakland University William Beaumont School of Medicine, Royal Oak, Mich.; secretary of federal affairs, American Academy of Ophthalmology
• member of the Retina Today editorial board
• financial interest: none acknowledged
gwilliams@beaumont.edu

 

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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.