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Article Date: 11/1/2013

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Coding Q & A

Modifier 25, Intravitreal Injections, and NCCI Bundles Clinical Applications


This column will focus on clinical applications relating to the use of Modifier 25 associated with intravitreal injections. The most important one is: “The initial evaluation is always included in the allowance for a minor surgical procedure.” Intravitreal injections are classified as minor, not because of a lack of respect for the seriousness of the procedure, but simply as a definition due to the 0-day global period. By having a 0- or 10-day global period, the physician can bill for the office visits and subsequent procedures performed within a reasonably short period of time — in the case of intravitreal injections (0-day global period), even the next day.


The National Correct Coding Initiative (NCCI) has three modifier-indicators, one of which is appended to every code pair edit. Indicator 1 is used to break the bundle for a sound medical reason. Indicator 0 indicates that the code pair edit can never be broken. Indicator 9 shows the edit has been deleted and is no longer relevant. Just because a methodology to break the code pair edit (bundle) exists does not mean it should be broken.

Modifier 25 is used to break bundles for minor surgical procedures, making the office visit eligible for payment (“Guidelines and Regulations Source Material,” page 14). Modifier 25 has been incorporated into the NCCI edits. However, its use has been necessary since 1999 whenever you wanted to receive payment for the office visit separately from the minor procedure.

For established and new patients, unbundling the office visit from the intravitreal injection is hardly ever warranted unless a different problem or emergent new symptoms occurs in the fellow eye. A new patient does not necessarily mean you are entitled to be reimbursed for the office visit separately.

When the RUC (Relative Value Update Committee) establishes a value for an eye examination, the typical patient is considered to have both eyes examined. An extra practice expense in processing a new patient is irrelevant to the bundling issue.


Medicare’s primary dictum is that any service billed must be medically reasonable and necessary, not that it be “good medicine.” Regarding office visits, not only does the service itself have to be medically necessary, so also must the performance of elements within the service for that specific visit.

If you believe you have a medically necessary visit you wish to bill in addition to the intravitreal injection, you must deduct all the history, examination, and medical decision-making that applies to the office visit performed for in the injection; you may only code what remains. This would usually be a level 2 or 3 E/M code or intermediate eye code. Comprehensive eye codes (CPT codes 92004/92014) have the mandatory elements of confrontation visual fields and evaluation of extra-ocular muscle balance. What would be the medical necessity of repeating these elements on a monthly or other short-interval basis, without identifying specific new symptoms warranting the tests?


Wet AMD, established patient

An established patient with wet AMD in both eyes being treated on a “treat and extend” basis returns for OCT. Assessing the OCT results, you then decide that you will give an intravitreal injection in the right eye today, with the patient returning for an injection in the left eye in two weeks. You have examined both eyes during the visit. Should you use modifier 25 to unbundle the office visit, making both the procedure and the visit eligible for payment? No. There is not “enough left over” from the included examination to bill for a separate office visit.

New patient with BRVO

A medical retinal specialist refers a new patient as an emergency after the patient had a recent onset (within the past five days) of BRVO in the right eye. The surgeon administers an intravitreal injection of bevacizumab (Avastin, Genentech, South San Francisco, CA) in the right eye after examining the patient (both eyes). No other significant ocular findings warrant treatment. May you bill for the office visit? The answer is no, as in the above case.

Retinal detachment found

An established patient presents for a scheduled intravitreal injection of ranibizumab (Lucentis, Genentech) in the left eye for wet AMD. The patient complains of flashes and floaters in the right eye, accompanied by decreased vision. You find an inferior retinal detachment. May you bill for the office visit?

Yes, because this is a significantly separate condition that is new to the examiner. Can you bill for the extended ophthalmoscopy on the right eye? Yes, it is definitely warranted, but only for the right eye. Because it is bundled, you will have to use modifier 59 on the extended ophthalmoscopy.

Furthermore, you should use 92225, because this is the initial presentation of this problem.

Tips for using Modifier 25

Medicare’s RUC assigns values to codes, including office visits, based on the examination of both eyes. It assigns values based on examination of a typical patient. The level of visit you choose must be based on what is left over after the examination performed for the problem that involves the procedure. CPT code 67028 already has examination time built into it.

Coding for a new patient does not necessarily warrant billing for the office visit when performed at the same session unless the examination uncovers new symptoms, diagnoses, or problems unrelated to its purpose and the procedure performed, namely the intravitreal injection. RP

Riva Lee Asbell can be contacted through her Web site,,where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.

Guidelines and Regulations Source Material

The Medicare Claims Processing Manual provides the following guidance on global surgical periods (from Chapter 12 - Physicians/Nonphysician Practitioners; sections 40/40.1):

A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all carrier jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than intended ...

Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and sometimes, YYY … Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies ...

Carriers do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 6 of the MFSDB. These services may be paid for separately … The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure ...

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.

If the Field entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.

From the CPT Manual

The CPT (Current Procedural Manual) provides the following guidance:

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required 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 to be reported (see Evaluation and Management Service Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of 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. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Retinal Physician, Volume: 10 , Issue: November 2013, page(s): 13 - 15

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