On May 27, 2025, HHS Office of Inspector General (OIG) issued a report outlining its finding that Medicare payments for evaluation management (E&M) services provided on the same day as eye injections were at risk for noncompliance with Medicare requirements. Based on its audit, OIG made three recommendations to CMS, including a recommendation that CMS update Medicare billing requirements.
Generally, an E&M service (which is performed to assess and manage a patient’s health) provided on the same day as an eye injection is included in the payment for the eye injection. However, Medicare may make a separate payment for an E&M service where the service was “significant, separately identifiable, and above and beyond the other service provided or beyond the usual preoperative or postoperative care associated with” the eye injection.
From June 2022 through May 2023, OIG conducted an audit intended to identify Medicare Part B payments for E&M services that were provided on the same day as eye injections that were “at risk for noncompliance with Medicare requirements.” Based on this audit, OIG found that providers billed for E&M services on the same day as 42% of eye injections by using modifier 25 (which allowed the provider to bypass system edits). OIG stated that its “data analysis suggests that providers may have been using the modifier incorrectly” to bill for E&M services on the same day as eye injections.
OIG also concluded that during the audit period, CMS paid $124 million for E&M services provided on the same day as the eye injections “because CMS’s internal controls were not adequate during [the] audit period to detect and prevent potentially improper payments.”
OIG made three recommendations to CMS, including:
- Update Medicare requirements to help providers understand the proper use of modifier 25;
- Conduct medical reviews to determine whether E&M payments made on the same day as eye injections were proper and recover improper payments made during the audit period (and instruct providers to refund any amounts improperly collected from enrollees); and
- Provide more education to providers regarding billing E&M services provided on the same day as eye injections and the appropriate use of modifier 25.
CMS provided written comments on OIG’s draft report that concurred with OIG’s second recommendation. CMS did not explicitly state its position on the first and third recommendations, though it stated that it had already met the requirements of the third recommendation.
The full report can be found here, and the report highlights can be found here.
