Eye care · Retina · Modifier 25
From 1 January, the injection visit pays less, and gets read more.
The CY2027 final rule pays the lower-paid service at 80% when an office E/M with modifier -25 is billed the same day as a 0-day procedure such as 67028. OIG has already found most sampled same-day E/Ms with eye injections unsupported. Here is the math and the documentation line to hold.
By ASP-RCM Editorial, Healthcare RCM Practice · Updated
Less per 99214-25 + 67028
2027 national office amounts: 67028 drops from $108.65 to $86.92
Injections with a same-day E/M
OIG, Medicare claims June 2022 to May 2023
Sampled E/Ms not supported
OIG found the documentation did not support modifier 25
Recovery recommended
OIG asked CMS to review and recover up to $123,955,176. Still open; update expected 14 Apr 2027
Worked example: same-day E/M plus 67028 at 2027 national amounts
An illustration using CY2027 national, non-facility Medicare amounts only. It is not a client result. The drug is billed on its own line and is not part of this reduction.
| Same-day pair | Full 2027 amounts | Paid under the final rule | Change per encounter |
|---|---|---|---|
| 99213-25 + 67028 | $92.01 + $108.65 = $200.66 | $73.61 + $108.65 = $182.26 | -$18.40 |
| 99214-25 + 67028 | $131.17 + $108.65 = $239.82 | $131.17 + $86.92 = $218.09 | -$21.73 |
| 99215-25 + 67028 | $183.37 + $108.65 = $292.02 | $183.37 + $86.92 = $270.29 | -$21.73 |
Rule: the highest-paid service that day is paid at 100%, every other service at 80%. With 99213 the injection is the higher service, so the visit is reduced. Amounts are total RVUs from the CY2027 final Addendum B times $32.6286. Your locality and contracts will differ.
How to decide the same-day visit, in the right order
The payment rule comes last. The chart decides whether a separate visit exists and which code family fits.
Is there a separate problem?
Work beyond the injection decision: new symptoms, a fellow-eye problem, or a change in the treatment plan. The injection decision itself belongs to 67028.
Document it on its own
The note shows what was evaluated beyond the usual pre-injection work, and the diagnosis that drove it.
Pick the code family from the note
Eye codes 920xx are leveled by exam elements. Office E/M 992xx is leveled by MDM or total time.
Then let the rule apply
If the visit is 99202-99215 with -25, the lower-paid line is paid at 80%. Post it as expected, not as a short-pay.
920xx vs 992xx: what has to be in the chart
The final rule's code list names only 99202-99215. That does not make 920xx a workaround. CMS said it will monitor billing patterns, and each family has its own requirements.
Eye visit codes 92002-92014
- Comprehensive 92004/92014: all 12 exam elements
- Intermediate 92002/92012: at least 3 but fewer than 12 elements
- Always the initiation or continuation of a diagnostic or treatment program
- If dilation is skipped on a comprehensive exam, the note says why
Office E/M 99202-99215
- Level set by medical decision making or total time on the date
- MDM needs two of three elements at the chosen level
- History and exam documented as medically relevant, not counted
- With an injection, it must be significant and separately identifiable
What CMS and OIG are signalling
CMS wants more detail
The final rule asked how same-day exams with injections should be treated: fellow eye, new patients, diagnosis codes. CMS will consider the answers for future rulemaking.
CMS will watch scheduling
CMS called scheduling services to maximize payment problematic and named claims edits, comparative billing reports and medical review as its tools.
OIG wants a clear line
OIG told CMS to stress that the decision to inject is part of the procedure, and to define what is above and beyond the usual injection care.
How we got here
- 27 May 2025
OIG A-09-23-03014: E/M on the same day as eye injections at risk for noncompliance.
- 11 Feb 2026
OIG closes its billing-requirements recommendation as implemented.
- 8 Sep 2026
OIG closes its provider-education recommendation as implemented.
- 4 Nov 2026
CMS-1848-F finalizes the 20% same-day reduction for 0-day globals.
- 1 Jan 2027
Reduction applies to dates of service from this day.
- 14 Apr 2027
Next OIG update expected on the open medical review and recovery recommendation.
Check five recent injection-day charts
Pull five same-day E/M plus 67028 encounters and tick what is true for all five.
On the same day as 67028, bill a visit only when the chart shows separate work, choose 920xx or 992xx from what the note supports, and expect the lower-paid line at 80% from 1 January. The cut is about $18 to $22 nationally per encounter; an unsupported visit can cost the whole E/M.
Questions operators ask next
Is 67028 a 0-day global procedure?
Yes. In the CY2027 Physician Fee Schedule Addendum B, CPT 67028 (intravitreal injection of a pharmacologic agent) carries a 000 global period. That puts it inside the final same-day rule: when an office/outpatient E/M 99202-99215 is billed the same day by the same practitioner or same-specialty group member, the lower-paid service is paid at 80% from 1 January 2027.
Can I bill an E/M with modifier 25 on the same day as an intravitreal injection?
Yes, when the visit is significant and separately identifiable from the injection. OIG's 2025 audit found 22 of 24 sampled same-day E/Ms did not support modifier 25 and recommended CMS stress that the decision to inject is part of the procedure. Document the separate problem, assessment and plan.
Does the 2027 same-day reduction apply to 92014 billed with 67028?
The final rule lists only office/outpatient E/M codes 99202-99215. Eye visit codes 92002-92014 are not on that list. CMS also said it will monitor for problematic patterns, so the code family must follow the documentation: 920xx by exam elements and a treatment program, 992xx by MDM or time.
How much does the 2027 rule reduce a 99214 plus 67028 visit?
At CY2027 national non-facility amounts, 99214 is $131.17 and 67028 is $108.65. 99214 is the higher service, so 67028 is paid at 80%, or $86.92. The encounter falls from $239.82 to $218.09, a $21.73 difference before locality adjustment. The drug line is paid separately.
Want to know how your retina visits would hold up in a review?
Send us a sample of same-day E/M plus 67028 encounters. A senior retina coding lead checks each one against the separately identifiable standard and shows the 2027 payment effect, in a free 30-minute call with a written gap report after.
Keep reading
Sources
- CMS fact sheet, CY2027 Medicare Physician Fee Schedule final rule, 4 Nov 2026
- Federal Register public inspection, CY2027 PFS final rule (2026-22743)
- CMS, CMS-1848-F rule page and Addendum B
- HHS-OIG, A-09-23-03014, E/M services on the same day as eye injections, May 2025
- AAO, How to choose between E/M and Eye visit codes
- AAO EyeNet, Fact sheet for the comprehensive Eye visit codes 92004 and 92014
Checked November 6, 2026. Amounts are national and unadjusted. CPT codes are copyright American Medical Association. General information on coding and billing operations, not legal or coding advice for a specific chart.