The Centers for Medicare & Medicaid Services and the Office of Inspector General are drawing attention to improper billing practices involving evaluation and management (E/M) services billed alongside intravitreal injections. Recent findings show that modifier 25 has been incorrectly applied in cases where the E/M service was not truly separate from the procedure, increasing the risk of improper payments and audit exposure. Providers are reminded that modifier 25 should only be used when documentation clearly supports a significant, separately identifiable service unrelated to the procedure itself. CMS has also released updated educational resources to help clarify correct billing practices.
In parallel, CMS announced a new optional Substance Access Beneficiary Engagement Incentive through its Innovation Center, allowing certain participating organizations to incorporate eligible hemp-derived products into care plans under clinician guidance. Available beginning April 1, 2026, this model-specific tool is designed to support patient-centered care approaches within select alternative payment models, while remaining outside of traditional Medicare coverage and reimbursement structures.
Resource: MLN Connects® Newsletter