Advocacy & Practice Updates — Advocacy & Practice

Are You Ready for Reactivation of CMS’ Injection Bundles?

May 2, 2014    --    Back to Retina Practice News

Kirk A. Mack, COMT, COE, CPC, CPMA
Senior Consultant
Corcoran Consulting Group

Following the unexpected July 1, 2013 National Correct Coding Initiative (NCCI) edits[1] that bundled eye exams with minor surgical procedures, including intravitreal injections, there was widespread confusion and complaints about denied claims.  According to a letter from the NCCI Medical Director to the American Academy of Ophthalmology (AAO), the claims for office visits 92012 and 92014, with modifier -25 appended, should have bypassed this NCCI edit, however the computerized claims processing system failed.[2]  The Medicare Claims Processing Manual (MCPM), Chapter 12§40.3.C Exclusions from Prepayment Edits,[3] specifically states, “Carriers exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met:  Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”  Consequently, these NCCI edits were inactivated until now.

On April 4, 2014, the NCCI Medical Director notified the American Society of Cataract and Refractive Surgeons of the reactivation of these NCCI edits.  The reactivation is effective April 1, 2014, however implementation begins July 1, 2014.  This means the reactivation is “retroactive” to April 1, 2014.  When these edits are reactivated July 1, 2014, any claims received after July 1, 2014, for dates of service April 1, 2014, or later will be subject to the edits, but any claims filed before July 1, 2014, for same dates of service will not be re-adjudicated.[4]  The computerized claims processing system is presumably repaired and will allow modifiers 24, 25, or 57 to process with 92012 and 92014.  Specifically, 92012 and 92014 with modifier -25 appended, will adjudicate properly, and permit reimbursement, when billed with an intravitreal injection (67028). 

This brings us to the ongoing debate regarding the appropriate use of modifier -25 to claim reimbursement for an office visit on the same day as an intravitreal injection or other minor procedure.  By definition, a minor surgery has a zero or 10-day postoperative period.  Intravitreal injections (67028) have zero postop days.  The same letter notifying ophthalmologists that the NCCI edits would be reactivated, also provides some guidance for using modifier -25.  The letter states; “An E&M service is separately reportable on the same day as a procedure only if significant and separately identifiable.  An E&M service should not be reported solely for the decision to perform the minor surgical procedure.”[5] 

One of the most common questions we receive is, “Can I bill an office visit with an injection on the same day?”  We answer, sometimes.  Since a retinal specialist must evaluate the eye to determine the need for an injection, there is widespread belief that separate reimbursement for this exam is warranted.  Nevertheless, as cited above, if the only reason for the exam is to determine the need for an injection, the use of modifier 25 to bill a visit is not supported, and separate reimbursement will not be made. 

CMS provides guidance on the use of modifier -25 in the MCPM Chapter 12§40.1.C stating, “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.  For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.”[6] In other words, a visit is included in the payment of a minor procedure. CMS goes further in the MCPM (Chapter 12§40.2.A.4) to discourage routine billing of an office visit/evaluation with a minor procedure.  “Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.”[7]

Considering these guidelines from CMS, reviewing several cases studies will add perspective.

CASE 1 – New Patient with Wet AMD and Dry AMD

Your new patient complains of reduced vision, OD>OS.  On exam, you find wet AMD OD, and dry AMD OS.  You plan to treat the OD with an anti-VEGF agent and recommend the patient begin taking AREDS.  In this case, the exam is separately identifiable due to the evaluation and management of the OS for dry AMD and represents much more than a decision to inject OD.  As a new patient with bilateral complaints, an evaluation of both eyes has merit and modifier -25 is supported for the work on the unoperated eye.

CASE 2 –Established Patent with Wet AMD and Dry AMD

Your established patient returns six (6) weeks following an anti-VEGF injection of the OS.  The wet AMD OS remains active with fluid and you deliver the eighth injection for the OS.  The patient has received an anti-VEGF injection in the OS, every 4 to 6 weeks.  At every visit, you evaluate the fellow eye (OD) finding stable dry AMD.  That is difficult to support because the customary interval for re-evaluating dry AMD is longer than 4-6 weeks.  You have to ask yourself the question – “If the patient was not coming in to the office for an injection OS, would I have brought them in to evaluate the OD?”  If your answer is “No”, than modifier -25 is not justified and a visit should not be charged with the injection.

Some physicians have told us the fellow eye should be evaluated every 3-4 months (or sooner with new signs/symptoms) making an office visit with modifier -25 appropriate 3-4 times per year (with exceptions).  The decision to re-evaluate remains with the surgeon to do what is clinically best for each patient and bill accordingly. 

CASE 3 –Bilateral wet AMD

Your established patient with bilateral active wet AMD returns 4 weeks after bilateral injections of anti-VEGF for evaluation and possible injection OU.  Your evaluation confirms active wet AMD OU and anti-VEGF is injected OU.  In this case, both eyes have active wet AMD and both eyes receive an intravitreal injection.  In this case, modifier -25 is not warranted.

It’s important to note that ancillary diagnostic tests, such as OCT or FA, are not handled in the same way as the office visit, and are reimbursed.


The NCCI edits which bundle eye codes 92012 and 92014 with intravitreal injection (67028) will be reactivated on July 1, 2014 with an effective date of April 1, 2014.  When this occurs, modifier -25 should permit payment of an office visit on the same day as an injection.  Due to the continuing controversy surrounding use of modifier -25, consider carefully whether there is an appropriate justification to use it consistent with CMS guidance.


5. Ibid.

7. Ibid.