Elizabeth Cifers on Coding Risk, Modifier -25 Enforcement, and the Rise of Pre-Pay Audits

Hosts:John Kitchens, MDScott KrzywonosGuest:Elizabeth CifersFounder & Principal Consultant, Elizabeth Cifers ConsultingShow Summary:In this episode, RetinUp introduces a new recurring segment, Vitreoretinal View, focused on surgical innovation and next-generation vitrectomy platforms. John breaks down where vitreoretinal surgery is headed, and comments on Alcon’s UNITY VCS system, flow-based vitrectomy, and his expectations for the next wave of surgical innovation.But first, the conversation kicks off with a discussion of drug access and policy, as John and Scott revisit Outlook Therapeutics’ unsuccessful attempt to secure FDA approval for ONS-5010, an ophthalmic formulation of bevacizumab. They explain why continued access to compounded bevacizumab remains critical for affordability and patient choice.In the second half, the hosts sit down with Elizabeth Cifers, one of the country’s leading ophthalmic coding and compliance experts. Elizabeth offers a clear-eyed assessment of Modifier -25 and Modifier -59, why enforcement has intensified, and how CMS’s shift from post-pay recovery to pre-pay, AI-driven audits is fundamentally changing compliance risk for retina practices heading into 2026. (Do you think your practice’s billing and coding staff would find this episode helpful? If so, share it with them—and tell them to send us feedback by emailing us at [email protected].)Topics Covered:Why Outlook Therapeutics’ FDA rejection preserves access to compounded bevacizumabEconomic and regulatory risks of an FDA-approved bevacizumab alternativeLaunch of the Vitreoretinal View surgical segmentNext-generation vitrectomy platforms and workflow efficiencyAlcon UNITY VCS vs. the legacy Constellation systemsFlow-based vs. Venturi-based vitrectomySurgical innovation amid declining reimbursementWhat Modifier -25 actually requires — and common misconceptionsProper and improper use of Modifier -59Documentation gaps that trigger auditsCMS’s shift to AI-based anomaly detectionPre-pay vs. post-pay audits and what practices should expectHow retina practices can prepare for changes in coding enforcement without overcorrectingKey Quotes:“The medicine is usually good. It’s the documentation that doesn’t support what’s being billed.” — Elizabeth Cifers“With the algorithms CMS has now, [the question of whether you’ll be hit with an audit] is not an if — it’s a when.” — Elizabeth Cifers“Compounded bevacizumab remains one of the most important access tools we have in retina.” — John Kitchens, MDGuest Info:Visit elizabethcconsulting.com to learn about how Elizabeth Cifers.Sign up for her newsletter here, where Elizabeth shares actionable tips and strategies to help you run a more efficient, compliant, and profitable retina practice.