Coding Q&A

Avoiding Audit Traps: Office Visits and Intravitreal Injections


Avoiding Audit Traps: Office Visits and Intravitreal Injections


Q. Can we bill an office visit when we are doing an intravitreal injection or do we just bill for the injection?

A. This issue has been the reason for many audits, both Medicare and non-Medicare. My answer is based on Medicare guidelines.

When a procedure is performed in the office in the same session as the office visit, the office procedure may be separately reimbursable if certain criteria are met. Let's take a look at some of the issues.

Background. Separate reimbursement can be obtained by appending modifier 25 to the office visit/consultation when the procedure is minor (global period of 0 or 10 days), or modifier 57 when the procedure is classified as major (global period of 90 days). An intravitreal injection (CPT code 67028) has a global period of 0 days, and thus is classified as a minor procedure.

Definition. The following CPT definition of modifier 25 addresses many of the critical issues. "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician 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.

Practical Application. The decision on whether or not you should apply the modifier to obtain reimbursement for the office visits depends on your practice patterns for intravitreal injections and your chart documentation.

Example 1. Patient A is being treated with ranibizumab injections for wet AMD using a protocol of intravitreal injections being given at fixed intervals. The chart note states that patient is to return for next intravitreal injection in 4 weeks.

In this case, you do not have medical necessity to bill for the office visit since the decision has already been made and the purpose or reason for the encounter is for the injection.

It makes no difference that you examine the patient — in these cases intent rules.

Example 2. Patient B is being treated with ranibizumab injections for wet AMD; however, in this case the decision on further treatment (intravitreal injection) is made depending on the OCT findings (OCT performed after last office visit). The physician reviews the OCT with the patient, examines the patient and the decision is then made to proceed with an intravitreal injection that day.

In this case, you may apply modifier 25. Note: your chart documentation from the prior visit should state that patient is to return after OCT and further evaluation — not for the injection!

  • Remember that you do not need 2 separate diagnoses.
  • Modifier 25 can be applied to either the E/M codes or the Eye codes.
  • Examining the patient in and of itself does not constitute medical necessity for billing the office visit. RP

CPT codes copyright 2006 American Medical Association.

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