Can You Bill an Office Visit on the Same Day as an Eye Injection?
Modifier 25 is a billing code that lets a practice report a significant, separately identifiable office visit on the same day as a minor procedure such as an intravitreal injection. As of August 2026, a $3.9 million federal settlement has made clear that Medicare pays the same-day visit only when the documentation supports a service distinct from the injection itself. The routine pre-injection assessment is not separately billable.
A settlement, not just a warning. On July 31, 2026, a Massachusetts practice agreed to pay $3,902,588.28 over modifier 25 on same-day injection claims. This is enforcement, not guidance.
Documentation is the whole test. A same-day visit must record separate history, exam, and decision-making. Repeating the injection workup does not qualify.
The injection already includes some work. CPT 67028 carries its own pre-service assessment, so the standard check before a planned injection is bundled into it.
A $3.9 Million Ophthalmology Settlement
On July 31, 2026, the U.S. Attorney’s Office for the District of Massachusetts and HHS-OIG announced that Ophthalmic Consultants of Boston agreed to pay $3,902,588.28 to resolve False Claims Act allegations. According to the government, between January 1, 2015 and July 30, 2025 the practice billed Medicare and MassHealth for office visits on the same day it administered intravitreal injections, using modifier 25 even when it did not have documentation to support the separate charge.
The core allegation is narrow and specific. Medicare and Medicaid do not permit billing an office visit in addition to the injection itself except under special circumstances, and the government contended that the practice’s modifier 25 claims did not meet that bar. The result was a multimillion-dollar recovery over a single, everyday billing decision that plays out in retina clinics thousands of times a week.
For an ophthalmology or retina practice, this is not an abstract compliance story. It is a direct signal about a code your team almost certainly touches on a daily basis, and it lands at a moment when federal reviewers were already looking hard at the same pattern. If you want the underlying mechanics of how eye claims and modifiers fit together, our ophthalmology medical billing and coding guideline covers the foundation.
Which Practices Does This Affect?
Any practice that administers intravitreal anti-VEGF injections and also bills office visits is exposed here, which means retina specialists first, but also comprehensive ophthalmologists who inject for wet age-related macular degeneration, diabetic macular edema, diabetic retinopathy, and retinal vein occlusion. If your claims regularly pair an evaluation and management service with CPT 67028 on the same date, this settlement is about you.
The exposure scales with volume, and injection volume in ophthalmology is enormous. Across the billing companies we vet, the most common compliance gap we see on retina claims is a reflexive modifier 25 attached to nearly every injection visit, applied out of habit rather than because a separate service was performed and documented. When a high percentage of a practice’s injection claims carry a same-day E/M, that pattern is exactly what draws a reviewer’s eye.
It also reaches beyond retina. Comprehensive ophthalmologists who bill an eye exam code such as the comprehensive eye exam code 92014 on the same day as a minor procedure face the same question: was the exam significant, separately identifiable, and documented as such, or was it part of the procedure?
Why the Scrutiny Is Rising
This settlement did not appear out of nowhere. It follows a coordinated federal focus on modifier 25 that has been building for more than a year. In an OIG audit report on evaluation and management services billed on the same day as intravitreal injections (report A-09-23-03014, released in May 2025), the OIG found that providers used modifier 25 with 42 percent of intravitreal injections during the study window.
Between June 2022 and May 2023, Medicare reimbursed physicians for roughly 3.3 million intravitreal injections and about 1.4 million claims for E/M services billed with modifier 25 on the same day as an injection. When more than four in ten injection visits carry a separately billed exam, reviewers read that as a rate worth testing against documentation.
What makes intravitreal injections a natural target is the economics. Injections are high-frequency and high-dollar, and they are administered on a schedule, which means the same code pairing repeats predictably across a patient’s treatment year. When a service is both lucrative and routine, a small percentage of unsupported claims adds up to a large recovery, and it is easy for an automated review to spot the pattern in claims data.
When Can You Bill an Office Visit With an Injection?
You can bill a same-day office visit with an intravitreal injection only when the visit is a significant, separately identifiable service beyond the work of the injection, and only when your note documents it. The routine assessment that precedes a planned injection is bundled into CPT 67028, which carries a 0-day global period, so it is not a separate charge.
| Situation on the day of the injection | Separately billable? | Documentation Medicare expects |
|---|---|---|
| Planned injection with usual pre-injection check | Generally no | Routine assessment is part of the injection service (CPT 67028) |
| New or worsening problem evaluated same day | Potentially yes, with mod 25 | Distinct history, exam, and MDM tied to the separate problem |
| Different, unrelated eye condition addressed | Potentially yes, with mod 25 | Clearly separate, standalone note for the unrelated issue |
| Routine interval monitoring only | Generally no | Not separately identifiable from the planned injection |
What Should Your Practice Do Now?
Providers often come to us after a payer or a contractor requests records on a batch of same-day E/M claims, when the safer move would have been to tighten the pattern before anyone asked.
- Audit your modifier 25 rate on same-day injection claims. Compare it against the OIG benchmark, since a rate near or above the reported 42 percent invites a closer look.
- Document a separate service, not a restatement. Record distinct history, exam, and medical decision-making for the separate problem, not the routine injection workup.
- Bundle the routine pre-injection assessment. Treat the standard check before a planned injection as part of CPT 67028, not as its own visit.
- Tie the E/M to a distinct diagnosis where one exists. Link the office visit to the separate condition it addresses rather than the injection diagnosis.
- Educate providers on the 67028 global structure. Make sure clinicians understand the injection already includes its own pre-service work.
- Run a pre-bill edit on E/M-plus-injection pairs. Flag same-day combinations for a documentation check before the claim goes out.
- Keep records ready for a look-back. Retain notes that would hold up if a contractor reviews prior-year claims, since settlements reach back years.
Worried your modifier 25 pattern would not survive a review? Get matched with a vetted ophthalmology billing partner that audits same-day E/M and injection claims before they go out the door.
Common Modifier 25 Mistakes
The mistakes that create exposure are rarely dramatic. The most frequent is the reflexive append, where modifier 25 goes on every injection visit by default because the practice management system was set up that way years ago. The second is documentation that simply repeats the injection assessment in different words, which does not create a separately identifiable service no matter how long the note runs.
Billing a same-day E/M for routine interval monitoring, when the visit exists only to administer a planned injection, is a direct target of the OIG finding. And linking the office visit to the same diagnosis as the injection, with no separate problem in the record, tells a reviewer the two services were really one.
Finally, practices underestimate the look-back. The OCB conduct period stretched from 2015 to 2025, a full decade, which means a modifier 25 habit is not a this-quarter problem. It is a standing liability that compounds every time the pattern repeats, and it does not resolve itself until the documentation practice changes.
Modifier 25 vs Modifier 57: Which One Applies?
Modifier 25 applies to a significant, separately identifiable E/M on the same day as a minor procedure, which is the category an intravitreal injection falls into given its 0-day global period. Modifier 57 applies to an E/M that results in the decision to perform a major surgery with a 90-day global period. For same-day injection claims, modifier 57 is the wrong tool. The decision to take a patient to the OR for a cataract extraction is where modifier 57 can belong. The same-day exam that accompanies a scheduled anti-VEGF injection is where modifier 25 is the relevant question.
In-House vs Outsourced Compliance
A single biller can keep up with a handful of injection claims a day. What is hard to sustain in-house is the discipline this settlement demands at scale: a defensible documentation standard on every same-day visit, a running audit of the modifier 25 rate, and pre-bill edits that catch the reflexive append before submission.
In our experience matching providers with billing partners, the practices that survive a modifier 25 review are the ones whose documentation was built to be separately identifiable from the start, not reconstructed after a records request. You do not have to outsource the whole revenue cycle to close this gap. Even a practice that keeps billing in-house can bring in a vetted partner to audit its same-day E/M pattern and rebuild the documentation template. For a broader view of how compliance fits into the revenue cycle, see our ophthalmology revenue cycle management guide.
Frequently Asked Questions
Yes, but only when the visit is significant and separately identifiable from the injection and your documentation proves it. The routine assessment before a planned injection is bundled into CPT 67028 and is not separately billable. Modifier 25 is required when the separate service is supported.
Modifier 25 is appended to an evaluation and management code to report a significant, separately identifiable service performed on the same day as a minor procedure. It tells the payer the visit was distinct from the procedure. Without supporting documentation, it can turn a claim into an overpayment.
On July 31, 2026, Ophthalmic Consultants of Boston agreed to pay $3,902,588.28 to resolve False Claims Act allegations. The government alleged the practice used modifier 25 to bill same-day office visits with intravitreal injections from 2015 to 2025 without documentation supporting the separate charge.
In OIG report A-09-23-03014, released in May 2025, the OIG found modifier 25 was used with 42 percent of intravitreal injections during the study window. That high rate is part of what drove expanded audit activity and the enforcement that followed.
Yes. CPT 67028 carries its own pre-service work, including the routine assessment that precedes a planned injection, and it has a 0-day global period. That built-in work is why a standard pre-injection check is not separately billable as an office visit.
A modifier 25 rate that is high relative to peers is the main trigger, especially on same-day injection claims. Contractor reviews such as the SMRC modifier 25 project, and patterns flagged in OIG audits, can prompt records requests that reach back several years.
The claim is at risk of being treated as an overpayment, and a pattern of unsupported modifier 25 claims can lead to False Claims Act exposure, as the OCB settlement shows. Recoveries can reach into the millions because reviews look back across many years of claims.
Next Steps
- Start by auditing your modifier 25 rate on same-day injection claims and tightening the documentation template before a payer asks.
- Review how the exam side is coded with our guide to the comprehensive eye exam code 92014.
- Pressure-test your compliance and denial exposure with our ophthalmology revenue cycle management guide.
Federal reviewers are actively working same-day E/M and injection claims, and settlements reach back years. Get matched with an ophthalmology billing partner that keeps your modifier 25 documentation clean and audit-ready. Ophthalmology Bill Co connects you with vetted billing companies across all 50 states, with over 15 years in medical billing and rates from 2.95 percent. Matching is 100 percent free.
