• HHS Inspector General to Review Medicare Part B Claims for Eylea, Lucentis Injections


    The Academy has learned that U.S. Department of Health and Human Services plans to review a sample of Medicare Part B claims for intravitreal injections of Eylea and Lucentis, as well as office visits and diagnostic tests associated with such injections.

    In an announcement issued this week, the agency’s Office of Inspector General said it will review claims submitted to the Centers for Medicare & Medicaid Services for intravitreal injections of the two drugs as part of its 2019 work plan. It will also review claims for other physician services billed on the same day as the injections, including evaluation and management (E/M), to determine whether they were reasonable, necessary and met requirements.

    The OIG has reviewed ophthalmology claims for Part B drugs before. In 2014, OIG reported $22.3 million in “potentially inappropriate” payments from Medicare contractors for 2012 and called for increased scrutiny over billing for ophthalmology services. In particular, OIG’s report singled out the excessive use of Lucentis.

    Intravitreal Eylea and Lucentis injections are used to treat wet age-related macular degeneration (AMD) and other retina diseases. Medicare typically pays for these injections separately from testing services (such as CPT code 92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina).

    Exams for established patients, when not performed solely to confirm the need for an injection, are also paid separately. To make sure that you’re billing appropriately, review our Academy resources: