Heads Up, Retina Practices: The Modifier-25 Storm Isn’t Over Yet
- pearlmanreid
- Jun 24
- 5 min read
By: Reid Pearlman, JD, CCEP, and Elizabeth Cifers, MBA, MSW, CHC, CPC
For some time, the direction of healthcare fraud, waste, and abuse enforcement has been uncertain, especially leading up to and since the start of the second Trump administration. Many assumed that the risk of enforcement would significantly decrease or vanish altogether due to leadership changes, agency restructuring, staff and budget cuts, and shifting priorities toward issues like immigration and tariff fraud.
But those assumptions were wrong. Recent developments have made it clear: enforcement is not only alive and well—it’s gaining speed.
Two Key Signals from the Government
First, the June 2025 HHS OIG Semiannual Report to Congress (covering October 2024 to March 2025) emphasized a striking $11-to-$1 return on investment for enforcement efforts, based on a projected $16 billion impact. That’s a 1,000% return—an impressive outcome by any standard and a strong incentive to continue targeting billing risk areas.
Second, the HHS OIG Office of Audit Services has released a long-anticipated Work Plan report on the use of Modifier -25 in retina care—a specialty rarely targeted. This study was prompted by prior OIG reports in Florida and California, as well as multiple whistleblower lawsuits, all of which centered on the use of Modifier -25 in conjunction with sequential intravitreal injection therapy.
Key Findings from the Modifier -25 Retina Audit
The OIG reviewed 24 Evaluation and Management (E/M) claims from June 2022 to May 2023 and found that Modifier -25 was used in 42% of encounters that occurred on the same day as a scheduled injection. Of those, 22 out of 24 claims lacked sufficient documentation to support the use of Modifier-25. That’s 92% of the total billed amount at risk for recoupment—and possibly reflective of a similar proportion of the $124 million billed nationally during the audit period.
So, what does the appropriate use of Modifier -25 actually look like?
Expert Insights from Elizabeth Cifers
To help clarify proper billing practices, we spoke with Elizabeth Cifers, a national expert in retina billing and coding compliance.
What does it mean to support Modifier -25 in the medical record?
The CPT definition of Modifier -25 states that the E/M service must be “significant and separately identifiable” from the same-day minor procedure. In retina, the same-day minor procedure is usually an intravitreal injection. Documentation must clearly reflect that the visit addressed something more than just the decision to perform the injection.
What documentation elements are required?
First, the visit note must not be cloned or copied from a prior encounter. Second, any documentation related to the injection itself does not contribute to the level of service billed. Only unrelated, medically necessary evaluations can support a separate E/M code. Without that, Modifier -25 is not justified.
Can you give an example of proper Modifier -25 usage?
Sure. Consider a patient scheduled for bilateral anti-VEGF injections who also complains of decreased vision. The physician performs an exam and notes the progression of cataracts, unrelated to the retinal condition. The injections proceed, but the physician also refers the patient for cataract evaluation. The cataract diagnosis and referral justify the Modifier-25, as they represent a significant and separately identifiable issue addressed during the visit.
What’s a common example of inappropriate use?
Say a patient is scheduled for an injection in the right eye and has no complaints. The physician examines the right eye and the documentation is identical to the prior visit. The left eye is not examined. The plan simply notes proceeding with the injection. If the E/M is billed solely because the physician confirmed the eye needed an injection, Modifier -25 is not warranted. The encounter lacks a separately identifiable service.
What’s a defensible percentage for Modifier -25 use in retina care?
This is a challenging question to answer, as the government hasn’t provided guidance on the use of Modifier -25. That said, the higher the utilization, the greater the risk of review by CMS or a payer. Conversely, lower utilization likely results in a lower risk for review; however, with the new administration, you never know. Ultimately, the chart documentation must support the medical necessity for addressing an unrelated issue on the same day.
What would you say to practices that believe they’re in the clear because they’ve passed audits in the past?
Many past audits have focused solely on the drug (e.g., J0178 or J2778), not the E/M service or Modifier -25 usage. Passing those audits means the documentation supported the drug, not necessarily the visit or modifier. Likewise, current Targeted Probe and Educate (TPE) audits may only assess the E/M service, not whether Modifier -25 was used appropriately, which can create a false sense of security. Each component must be separately defensible.
The Bottom Line: More Scrutiny Is Coming
Modifier -25 has existed for 25 years. Lucentis and Eylea have been covered for 18 and 14 years, respectively. And yet, payer enforcement around the improper use of Modifier -25 continues. Why? Because it’s easy to audit and easy to recoup.
For retina practices, the takeaway is clear: if you’re routinely using Modifier -25 with injections, expect increased scrutiny. That may come in the form of audits, extrapolated overpayments, clawbacks, or even False Claims suits in extreme cases.
Call to Action
Retina practices must evaluate their documentation habits now, not after receiving an audit notice. The recent OIG findings make it clear that the use of Modifier-25, particularly on injection days, is under scrutiny. To reduce your audit risk and ensure defensible billing practices, consider a proactive compliance review.
Working with a retina billing and compliance consultant, such as Elizabeth Cifers, can help your practice identify documentation and coding risks and implement practical, targeted solutions to strengthen compliance and protect revenue. Additionally, engaging a regulatory consultant such as Reid Pearlman, who brings a broader perspective on healthcare fraud and payer enforcement, may provide valuable insights and practical solutions into developing, implementing, and administering a tailored compliance program in your practice that addresses the full scope of regulatory risk.
Taking a team-based, expert-guided approach to compliance can help protect your revenue today and your reputation tomorrow.
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Reid Pearlman, JD, CCEP, is a healthcare regulatory compliance consultant and attorney. He is the principal of True Compliance Consulting, LLC in Atlanta, Georgia. He may be reached at Reid@MyComplianceOfficer.net.
Elizabeth Cifers, MBA, MSW, CHC, CPC, is a retina practice management consultant. She is the principal of Elizabeth Cifers Consulting, LLC in Moseley, Virginia. She may be reached at Elizabeth@ElizabethCConsulting.com.
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