By Sarah Callahan — Reviewed by Eman Zahra — Last updated: August 2026

Educational disclaimer: This article is general educational content about Medicare coding and audit policy. It is not legal, financial, coding-certification, or insurance advice, and it does not replace guidance from a certified coder, compliance officer, attorney, or your Medicare Administrative Contractor. Audit outcomes, error-rate figures, and CMS guidance change over time — verify current requirements directly with CMS, your MAC, or Noridian before making billing or appeal decisions.

The Short Answer

If your ophthalmology or retina practice bills modifier 25 on established-patient eye visit codes (92012, 92014) on the same day as an intravitreal injection (67028), you’re billing into one of Medicare’s most actively scrutinized code combinations right now. A federal audit found the large majority of a sampled group of these claims didn’t meet documentation standards, a national contractor has already completed a full audit cycle targeting the pattern, and as of mid-2026 ophthalmology’s own national societies are still pressing CMS for a clearer, injection-specific rule. The underlying standard hasn’t changed — you still need a genuinely separate, medically necessary E/M service, distinct from the routine pre-injection exam — but the odds that a given claim gets a second look have risen substantially since mid-2025.

What Modifier 25 Means in an Ophthalmology Context

The CPT/CMS definition

Modifier 25 tells a payer that a significant, separately identifiable evaluation and management service was performed by the same clinician on the same day as another procedure. Under Medicare’s global surgery policy, an office visit on the same day as a minor procedure is normally bundled into that procedure’s payment unless a separately identifiable service was also furnished and documented.

Why 67028 specifically triggers this rule

CPT 67028 (intravitreal injection of a pharmacologic agent — used for conditions like wet age-related macular degeneration and diabetic macular edema) is classified by CMS as a minor procedure with a zero- or 10-day global period. That classification is the entire reason this issue exists: Medicare assumes the routine pre-injection assessment of the treated eye is already paid for inside the injection fee. Modifier 25 is only appropriate when the visit did more than that routine work.

Modifier 25 attaches to the E/M or eye-visit code (92012, 92014, or 99202–99215) — never to the procedure code. CMS coding policy is explicit that modifiers 24, 25, and 57 may only be appended to E/M codes and eye-visit codes, not to surgical or procedure codes like 67028.

Timeline: How We Got Here (May 2025–2026)

May 2025 — The OIG report. HHS’s Office of Inspector General reviewed intravitreal injection claims from June 2022 through May 2023 (Report A-09-23-03014) and found that providers billed modifier 25 alongside 42% of intravitreal injections during that period. On a manual review of a 24-claim sample drawn from all 12 Medicare Administrative Contractor jurisdictions, 22 of the 24 claims — 92% — did not meet Medicare’s modifier 25 documentation requirements. OIG recommended CMS clarify the guidance, conduct targeted medical review, and provide additional provider education, and CMS agreed to the medical-review recommendation.

Mid-2025 to March 2026 — The SMRC audit. CMS directed Noridian, the national Supplemental Medical Review Contractor, to audit established-patient eye visit codes billed with modifier 25 on the same day as an intravitreal injection, covering the same June 2022–May 2023 window as the OIG sample (Project 01-146). Reported results of that project diverge depending on the source, and a careful reader should know both figures rather than rely on just one:

Source	Reported error rate	Framing
AAO advocacy page, citing Noridian Project 01-146 (audits concluded March 2026)	7%	Cited as evidence the original OIG sample wasn’t representative of typical practice
Ophthalmology Management coding column, citing the same Noridian project	30%	Described as a broader review result

Both figures trace back to the same Noridian project number but aren’t reconciled in either secondary source — they likely reflect different reporting cuts (claim-level vs. dollar-level, or different sampling scope). Practices should pull Noridian’s Project 01-146 results directly rather than anchoring to either number, since a 7% error rate and a 30% error rate imply very different audit exposure.

September 2025 — CMS updates its MLN guidance. CMS revised the Evaluation and Management Services MLN Booklet (MLN006764) to address modifier 25 with intravitreal injections. The update included an example suggesting that evaluating the uninjected fellow eye during a pre-injection visit is not, by itself, separately billable unless that exam reveals a new diagnosis requiring a distinct management plan. Ophthalmology’s coding experts read this as raising the bar beyond historical practice and introducing new ambiguity about what counts as “separately identifiable.”

April 9, 2026 — Societies push back. The AAO, ASRS, and AMA secured a meeting with CMS’s Division of Practitioner Services to argue that the MLN language was confusing rather than clarifying.

June 2026 — CMS responds. Following that engagement, CMS removed the disputed MLN language. As of this writing, no replacement injection-specific modifier 25 guidance has been issued — practices are effectively back to interpreting the general modifier 25 standard (a genuinely separate, medically necessary E/M service) without a bright-line ophthalmology-specific example from CMS.

What Actually Supports Modifier 25 on a Same-Day Claim

The clearest test used in the coding literature on this issue is a counterfactual one: if the patient were not receiving the injection that day, would this visit still have happened anyway?

• If no — the exam was performed to prepare for or follow up on the injection — it’s part of the procedure and not separately billable.
• If yes — the patient had a distinct, medically necessary problem that would have generated a visit regardless of the injection — modifier 25 may be appropriate.

Several things do not, on their own, justify modifier 25 under current CMS guidance:

• A second diagnosis alone. You need a medically necessary evaluation of the unrelated issue with its own assessment and plan — not just a second ICD-10 code attached to the visit.
• New-patient status alone.
• The time gap between the exam and the injection. There’s no minimum interval requirement.
• A more thorough exam. Extent of evaluation isn’t a determining factor — a detailed exam that’s still entirely injection-related doesn’t become separately billable just because it’s comprehensive.

What does support it: a documented, medically necessary evaluation and management of a problem distinct from the injection indication, with its own assessment and plan, clearly separable from the routine pre- and post-injection work.

Common Documentation Mistakes That Trigger Denials or Audits

1. Billing modifier 25 as a default on every injection visit, rather than case-by-case based on documented medical necessity. A pattern of near-100% modifier-25 usage on injection visits is exactly the kind of outlier billing behavior that gets a practice flagged for SMRC review in the first place.
2. Documenting a “comprehensive” exam of both eyes without a distinct diagnosis or plan for the non-injected eye. A thorough note isn’t the same as a separately billable note.
3. Relying on a chronic comorbid diagnosis (e.g., ongoing glaucoma management) without documenting active management decisions made that day, separate from the injection itself.
4. Appending modifier 25 to the injection code (67028) instead of the E/M/eye-visit code — an automatic denial risk that has nothing to do with documentation quality.
5. Cloned or copy-forward notes. If the “separately identifiable” section reads identically to the prior visit’s note, reviewers treat that as evidence the exam wasn’t distinct to that encounter.
6. Insufficient or late response to Additional Documentation Requests (ADRs). Non-response is treated as a payment error on its own, independent of whether the underlying service was billed correctly.

NCCI Edits vs. Modifier 25 — Two Different Issues

It’s worth separating this audit issue from an unrelated NCCI bundling edit that also touches 92012/92014. CMS maintains a separate procedure-to-procedure edit bundling certain retinal imaging codes (like OCT-angiography, CPT 92137) into 92002, 92004, 92012, and 92014, carrying a Correct Coding Modifier Indicator of 1 — meaning the edit can be bypassed with an appropriate NCCI-associated modifier when documentation supports it. That edit governs same-day imaging plus eye exam; it’s unrelated to the modifier 25/injection issue above, but the two are easy to conflate because they both touch 92012/92014.

If You Get an SMRC ADR Letter — Practical Next Steps

1. Respond within the deadline. Failure to respond to an Additional Documentation Request is treated as a payment error on its own, regardless of whether the underlying service was billed correctly.
2. Pull the full encounter note, not just the billing summary, and check it against the “would this visit have happened anyway” test above before submitting.
3. Don’t assume Medicare fee-for-service findings apply to Medicare Advantage, Medicaid, or commercial claims. Audit and appeal separately for each payer type.
4. Loop in your compliance officer or an outside coding auditor before responding if the sampled claims show a pattern (e.g., modifier 25 on nearly every injection visit for one physician) — a pattern finding can extrapolate to a much larger overpayment demand than the sampled claims alone.
5. Track the underlying guidance. CMS added, then withdrew, its MLN example within a nine-month span. Don’t build a permanent documentation template around language that’s already been pulled once — check for updated guidance periodically.

State, Payer, and Medicaid Variation

Everything above describes Medicare fee-for-service policy and a Medicare-focused federal audit. State Medicaid programs, Medicaid managed care plans, and commercial or Medicare Advantage payers are not bound by Noridian’s SMRC findings and may apply their own — sometimes stricter — modifier 25 edit logic. Always confirm current requirements with the specific payer’s provider manual or local coverage determination before applying this guidance to a non-Medicare claim.

FAQs

Does modifier 25 go on the injection code or the exam code? The exam/E/M code only (92012, 92014, or the applicable E/M code). Modifier 25 should never be appended to a procedure code like 67028.

Is there a minimum error rate that triggers a follow-up audit? No published threshold exists publicly. SMRC targeting is based on CMS data analysis of billing patterns rather than a single fixed error-rate cutoff.

Did CMS ever issue a clear, injection-specific rule for modifier 25? Not as of this writing. CMS added an example in September 2025 that ophthalmology groups considered overly restrictive, then removed that language in June 2026 after advocacy pressure — leaving practices to apply the general modifier 25 standard without an ophthalmology-specific bright line.

Does examining the fellow (non-injected) eye justify modifier 25? Not by itself. Under CMS’s now-withdrawn example, it would only qualify if that exam produced a new diagnosis requiring its own distinct management plan — and even with that language removed, the underlying “separately identifiable” standard still applies.

Methodology: This article draws on primary federal sources (HHS-OIG Audit Report A-09-23-03014; CMS Medicare Claims Processing Manual; CMS MLN booklets; CMS National Correct Coding Initiative Policy Manual) and secondary expert-analysis sources from the American Academy of Ophthalmology, the American Society of Retina Specialists, and coding-industry publications. Where sources reported conflicting figures for the same underlying audit, both figures are disclosed rather than reconciled by assumption. Last updated August 2026 — verify current CMS and Noridian guidance directly before making billing or appeal decisions, as this remains an actively evolving regulatory area.