Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements

Why OIG Did This Audit

• For June 2022 through May 2023 (audit period), Medicare paid $313 million for 3.3 million injections of drugs into the eye (i.e., intravitreal injections). Medicare also paid $124 million for 1.4 million evaluation and management (E&M) services billed with modifier 25 and provided on the same day as intravitreal injections.
• Prior OIG audits of individual providers found high improper payment rates for E&M services provided on the same day as intravitreal injections.
• This audit identified Medicare Part B payments to providers for E&M services that were provided on the same day as intravitreal injections and that were at risk for noncompliance with Medicare requirements.

What OIG Found

• For 42 percent of intravitreal injections provided during our audit period, providers billed for E&M services provided on the same day as injections using modifier 25, which allowed the claims to bypass system edits that are designed to prevent improper payments.
• To test provider compliance with Medicare requirements, we reviewed documentation for 24 sampled E&M services and found that documentation for 22 services did not support the use of modifier 25.
• CMS paid for E&M services billed with modifier 25 and provided on the same day as intravitreal injections that were at risk for noncompliance because CMS’s internal controls were not adequate during our audit period to detect and prevent potentially improper payments. During our audit period, Medicare paid $124 million nationwide for these services.

What OIG Recommends

We made three recommendations to CMS, including that CMS update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to help providers understand appropriate use of modifier 25, and conduct medical reviews of E&M services and recover payments of up to $124 million for those services that CMS determines should not have been billed with modifier 25 during our audit period. The full recommendations are in the report.

CMS concurred with one recommendation and did not indicate concurrence or nonconcurrence with two recommendations. CMS also described actions it had taken or planned to take to address all of our recommendations.

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