Modifier-25 same-day examinations are critical to the successful treatment and overall health and well being of these patients.
This article was reviewed by H. Alexander Leder, MD
Modifier-25 same-day examinations during anti-VEGF therapy for wet age-related macular degeneration (AMD) reduce treatment and travel costs, resulting in significant savings and improvement in the quality of life (QoL) for these patients in the United States, according to a study presented during the 2020 American Society of Retina Specialists virtual annual meeting.
Modifier-25 is a code that allows for the billing of an exam and injection on the same day in some circumstances. The practice is currently under scrutiny by payers for overuse and cost concerns.
Presenter H. Alexander Leder, MD, of Leder Retina and Uveitis, and colleagues compared the direct financial costs, appointment travel costs, and vision impact of four different wet AMD treatment paradigms: continuous monthly treatments with a minimum of two exams per year; the popular office-based treat-and-extend (T&E) protocol, which includes an office evaluation and optical coherence tomography (OCT) with each injection; pro re nata (PRN), which includes a monthly exam and OCT, but only including an injection when active disease is present; and injection series, in which a same-day exam with OCT imaging occurs at the beginning of each injection series to determine the number of injection-only visits needed for each cycle.
“It's a very simple study looking at four different protocols for treatment,” he said.
Direct cost was defined as the annual cost per patient for OCT imaging, exams, and the injection agent, calculated using 2017 provider utilization data. Travel costs included both the patient and caregiver brought to each visit. Health cost was defined as the lost vision in the fellow eye due to delayed diagnosis and treatment of wet AMD progression.
“When looking at the potential benefit from early detection of a conversion from dry to neovascular age-related macular degeneration, we made some assumptions that patients wouldn't present with symptoms but would be detected at their next exam, and also that the conversion from dry to wet happened midway between exams. So the more exams a patient had, the quicker they would be detected. And then we assume that all treatment modalities were equivalent in boosting vision along well-known improvement curves,” he said.
Office exams and OCT costs were higher in the T&E ($858), injection series ($497), and PRN ($1,685) protocols versus continuous treatment ($280). However, continuous treatment was more expensive annually when factoring in the cost of the anti-VEGF agent and number of required injections at $11,860 versus $10,131 for injection series, $6,858 for T&E, and $6,354 for PRN.
As expected, travel and caregiver costs were the lowest for T&E ($536) and highest for continuous treatment ($942).
Finally, in terms of vision, the researchers made a few assumptions to calculate vision lost and QoL impact of delayed diagnoses in the fellow eye. First, they assumed patients did not present when the fellow eye transitioned from dry to wet AMD, and that the disease progression was only found on an exam.
Second, they assumed that 6% of patients with dry AMD progressed to wet AMD, and that that transition occurred halfway between their scheduled exams. Finally, they assumed the patient was immediately started on treatment in the fellow eye, and that all treatment modalities were equally efficacious.
“This let us calculate the quality-adjusted life-year [QALY] benefit of all the protocols versus monthly treatment,” Leder explained. “And, in turn, we can calculate the incremental cost-effectiveness ratio, which is the ratio of the incremental cost versus the improvement in QALY.”
The researchers concluded that early detection of wet AMD in the fellow eye during same-day office examinations allows for a 2.1 and 1.8 QALY benefit per patient in the T&E and injection series groups, respectively, as compared to patients receiving continuous treatment, with a favorable $5,402 and $2,891 cost per QALY, respectively.
Finally, they calculated a total savings of $7.2 billion for patients on T&E and $2.7 billion for patients on injection series treatment paradigms, annually, as compared with monthly therapy.
The group concluded that modifier-25 same-day exams during anti-VEGF therapy for wet AMD should not only continue, but are critical to successful treatment and the overall health and well-being of wet AMD patients.
“Our model found that complete exams with both eyes [undergoing] OCT testing can reduce travel costs, treatment costs, and improve screening of the fellow eye, resulting in robust cost savings and improvements in QALY for improvement in vision in the fellow eye,” Leder said. “We conclude that it is important to advocate for our patients and retain the option to customize treatment to the different needs of each patient with exams and OCTs.”