Code 67028 is used to bill Medicare and Medicaid for intravitreal injection of a pharmacologic agent. In 2002, code 67028 was used approximately 4500 times in the Medicare database; in 2012, the code was used over 2 million times. The federal government, in an effort to save money in the Medicare system, has begun monitoring the use of modifier code -25 for cases when it is attached to code 67028. Modifier code -25 should be used for services that can be distinguished from the usual pre- and post-work of an evaluation and management (E&M) visit. To qualify for modifier code -25, the work should be obviously separate from normal treatment. Because intravitreal injections fall under the global theory of 0-day management, modifier code -25 may be used only if the additional services are delivered on the same day as routine E&M service.

EXAMPLES OF WHEN TO USE MODIFIER CODE -25

The American Medical Association’s guidebook on Current Procedural Terminology illustrates cases in which modifier code -25 should and should not be used. If someone is treated in an ER for a scalp laceration, the doctor who examines and sutures the wound should bill for only 1 procedure—that is, the examination and suturing are part of the same E&M procedure because they cannot be distinguished from each other. However, if the scalp laceration resulted from trauma that required to patient to undergo a neurological examination after suturing, then use of modifier -25 is justified: The neurological exam greatly exceeds the scope of standard E&M care and the procedure is distinguishable from any suturing that an ER physician would normally perform.

This hypothetical head trauma example sketches a useful scenario that helps us understand the correct use of modifier code -25. Let us translate that example’s teachings to the ophthalmology office. When a patient arrives in your office for a scheduled injection and receives said injection, modifier code -25 cannot be used: There was no distinguishably different service provided during this E&M visit because the decision to treat was already made. However, modifier code -25 is appropriate for some scheduled visits, even if a scheduled treatment is performed.

Consider the case of a patient who receives scheduled monthly injections for age-related macular degeneration (AMD) in 1 eye. Because AMD is a bilateral disease, semi-annual examinations of the fellow eye are justified. Upon examination, the patient presents symptoms of AMD in the fellow eye and the physician decides to preform an optical coherence tomography scan and an angiogram. After interpreting the results of those tests, the physician elects to treat both eyes. In this case, the decision to treat the fellow eye—arrived at because of the additional examination and tests—is distinct from the decision to treat the first eye. Thus, the use of modifier code -25 is justified.

GOVERNMENT INQUIRY

In cases in which Medicare is billed with modifier code -25, thorough documentation is critical. Continuing with the above hypothetical, it should be stated in the patient’s health record that the patient is usually treated monthly in 1 eye with intravitreal anti-VEGF injections and that, after performing a complete eye exam, the fellow eye showed symptoms of AMD. After running the appropriate scans, it was determined that treatment in the fellow eye was warranted. Such documentation protects a practice from accusations of inappropriate billing in the event of an audit.

The federal government is keeping an eye on the rates of use—and misuse—of modifier code -25 for intravitreal injections. In 2012, the US Department of Health and Human Services Office of Inspector General (OIG) investigated billing practices for code 67028. The investigation reviewed 100 cases in which code 67028 was used at the Fletcher Allen Health Care hospital system in Burlington, VT. Investigators found that the hospital incorrectly billed 85 of the 100 E&M cases it examined, resulting in $8100 in overpayments. Extrapolating those results, the OIG determined that the hospital overcharged $211 000 to Medicare between 2008 and 2010. The hospital was obligated to repay that sum. Still, 15 of the 100 cases the OIG reviewed properly billed intravitreal injections with modifier code -25, an apparent recognition, however tacit, that the modifier code -25 has a place in proper billing of code 67028.

Trexler M. Topping, MD, practices at Ophthalmic Consultants of Boston and Boston Eye Surgery & Laser Center. He serves on the Health Policy Committee at the AAO and the board of the ASRS. He may be reached at +1 617 367 4800.