Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B claims on certain ophthalmologic evaluation and management (E/M) codes billed with modifier 25 on the same date of service, by the same provider, for the same beneficiary that had an intravitreal injection billed. The dates of service under review are June 1, 2022, through May 31, 2023. Below are the review results:

Background

The Office of Inspector General (OIG) published a report, A-09-23-03014 in May 2025 titled, Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements. The OIG reported 42% of the intravitreal injections paid by Medicare also included payment for an evaluation and management (E/M) service billed on the same day as the intravitreal injection. Under limited circumstances, an E/M visit can be billed on the same day as a minor surgery, such as the intravitreal injection. The OIG estimated that Medicare paid approximately $124 million for the E/M services and recommended CMS conduct a medical record review of E/M services billed on the same day as the intravitreal injections.

Evaluation and Management services are medical services provided by physicians and other healthcare professionals to evaluate, diagnose, and treat a beneficiary’s health. The three key components to determine the level of E/M service are the beneficiary’s history, examination of the beneficiary, and the level of medical decision making (MDM) the provider has performed. Modifier 25 is appended to an E/M code to identify a significant and separately identifiable E/M service occurred on the same day by the same provider as a minor surgical procedure that was performed on the same beneficiary.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record review on claims billed with ophthalmologic E/M codes billed with modifier 25 on the same date of service, by the same provider, for the same beneficiary that had an intravitreal injection billed for dates of service June 1, 2022, through May 31, 2023.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the Additional Documentation Request (ADR)
  • Refer to 42 Code of Federal Regulations (CFR) Section (§)424.5(a)(6), Social Security Act (SSA) 1833(e) and SSA 1862(a)(1)(A). The requested records were not received.
• Separate Identifiable Service Not Performed
  • Refer to SSA 1862; Internet-Only Manual, Publication (Pub.) 100-04, Medicare Claims Processing Manual (MCPM), Chapter (Ch.) 12, §30.6.6. The documentation did not demonstrate a separate, identifiable service was provided outside the global surgery period. Documentation did not support the evaluation and management (E/M) visit billed was a significant and separately identifying service from the intravitreal eye injection procedure performed on the same date of service.
• Incorrect Date of Service (DOS)
  • Refer to Medicare Program Integrity Manual (MPIM) Ch. 3, §3.6.2.2. The documentation submitted was for the incorrect date of service.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

SSA, Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1848(c)(1)(A)(ii) Determination of Relative Values for Physicians’ Services
• §1861(s) Medical and Other Health Services
• §1862(a)(1)(A), (a)(7) Exclusions from Coverage and Medicare as a Secondary Payer
• §1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• §1893(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §410.20 Physician Services
• §410.3 Scope of benefits
• §411.15(k)(1) Particular services excluded from coverage
• §414.40 Coding and ancillary policies

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Final Rule and Interim Final Rule with Comments (IFC), Vol. 87, No. 222, November 18, 2022. Medicare and Medicaid Program: CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; and COVID-19 Interim Final Rules. CMS–1770–F, CMS–1751–F2, CMS–1744–F2, CMS–5531–IFC. Effective January 1, 2023. Retrieved from 2022-23873.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC
• Interim Final Rule with Comments (IFC), Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Effective March 1, 2020. Retrieved from CMS-5531-IFC

Internet-Only Manual (IOM), Publication (Pub.) 100-02, Medicare Benefit Policy Manual (MBPM)

• Chapter (Ch.) 6 Hospital Services Covered Under Part B
• Ch. 16 General Exclusion from Coverage

IOM, Pub. 100-04, Medicare Claims Processing Manual (MCPM)

• Ch. 1 General Billing Requirements
• Ch. 12, §30.6.6 Payment for Evaluation and Management Services Provided During Global Period of Surgery
• Ch. 12, §40.3 Claims Review for Global Surgeries
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. §§ 2022 and 2023
• National Correct Coding Initiative Policy Manual Chapter 1, Section D Evaluation & Management (E/M) Services
• National Correct Coding Initiative Policy Manual Chapter 1, Section E Modifiers and Modifier Indicators
• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 11, Section U Evaluation & Management Services

Other

• American Academy of Professional Coders (AAPC). Evaluation and Management Coding, E/M Codes. Evaluation and Management Coding, E/M Codes – AAPC
• American Medical Association (AMA). Evaluation and Management (E/M) Services Guidelines .January 1, 2023. Retrieved from 2023 CPT E/M descriptors and guidelines (ama-assn.org)
• American Medical Association (AMA) Reporting CPT Modifier 25
• Centers for Medicare and Medicaid Services (CMS) Medical Learning Network (MLN) ICN MLN006764 September 2024. Evaluation and Management Services Guide
• Office of Inspector General (OIG). May 2022. Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements. Report Number A-09-23-03014. Retrieved from Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements

Last Updated Mar 12, 2026