The use of modifier 25 to claim reimbursement for an exam on the day of a minor procedure has increased dramatically in recent years, especially by retinal physicians. Postpayment audits of modifier 25 continue to be an important topic to the Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and third-party payers.

Q. What is modifier 25?

A. CPT defines modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure.”¹ Using modifier 25 indicates that the patient’s condition required an exam beyond the usual preoperative and postoperative care associated with the procedure performed (eg, intravitreal injection).

Examples of “significant, separately identifiable” exams include

• A medically necessary exam of the eye that is not injected, and
• An exam of one or both eyes for a condition unrelated to the intravitreal injection.

Q. Isn’t an eye exam essential prior to the intravitreal injection? How are physicians paid for the exam?

A. Within Medicare’s global surgery package concept, the Relative Value Units (RVUs) assigned to the minor procedure include preoperative and postoperative exams. Billing separately for an eye exam on the day of a minor procedure is duplicative if it is related to the minor procedure. Only if the eye exam has nothing to do with the same-day minor procedure is separate payment possibly justified. So, if every intravitreal injection is billed with an eye exam, then Medicare would likely question the merit of the E/M or eye code.

Q. Will the use of modifier 25 attract attention from Medicare or other payers?

A. As long ago as 2002, the OIG of the Department of Health and Human Services reported that 35% of claims with modifier 25 did not meet requirements. Since then, OIG and others have repeatedly identified frequent errors with modifier 25. The OIG’s Work Plans have scrutinized misuses of modifier 25 and continue to do so. Excessive use of modifier 25 garners a lot of unwanted attention, particularly with respect to concurrent intravitreal injections.

Q. Are different diagnoses required?

A. No. The CPT definition of modifier 25 specifically states, “…different diagnoses are not required for reporting of the E/M services on the same date.” To appreciate this instruction, you should understand that it does not diminish or contradict the prior instruction with respect to the purpose of the visit. For example, your patient has exudative macular degeneration (ICD-10 H35.32) in both eyes. During today’s exam, you evaluate both eyes but inject only the left eye. There is just one diagnosis — it applies to both eyes. Modifier 25 applies, but for the exam of the eye that was not injected.

Q. Isn’t modifier 25 the same for a minor procedure as modifier 57 for a major surgery?

A. Under Medicare rules, the decision to proceed with major surgery constitutes a billable exam (with modifier 57); this is not the case for minor procedures (ie, those with 0 or 10 day global periods). The Centers for Medicare and Medicaid Services instructs, “where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.”² In November 2012, the American Academy of Ophthalmology addressed this issue; its coding bulletin specifically states, “If the need for the intravitreal injection has been established at an earlier visit and the patient is in the office solely to be injected, an E&M or Eye code service should not be billed.”³ CPT adds, “This modifier is not used to report an E/M service that resulted in a decision to perform surgery.”¹

Q: Does the use of modifier 25 affect the value of the exam?

A. Not for Medicare. Use of modifier 25 makes full reimbursement of the office visit and the minor procedure possible. Without it, the exam would be considered included in the procedure and not paid at all. Some non-Medicare payers have proposed to reduce the allowed amount for an exam billed with modifier 25, but we have not seen this implemented at this time.

Q. What is the best way to document a minor procedure?

A. The exam and minor surgery may appear on the same page in the medical record, but we don’t recommend it. We suggest a separate operative report for the surgery. It should contain the following:

• Heading with location, date, patient name, ID number
• Preoperative and postoperative diagnoses
• Indication(s)
• Procedure(s) performed
• Description of procedure(s), drugs used and discarded
• Complexity
• Discharge instructions
• Notes on time, intensity, and comparable procedures

A common weak point in an operative note is the description of drugs, units used, and “disposed or wasted.” RP

REFERENCES

1. American Medical Association. 2023 Current Procedural Terminology, Professional Edition. American Medical Association; 2023.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual Chap-ter 12 40.2.A4. Accessed March 14, 2023. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912
3. Vichrilli S. NCCI, part one: when can you unbundle? Eyenet. November 2012. Accessed March 14, 2023. https://www.aao.org/eyenet/article/ncci-part-one-when-can-you-unbundle?november-2012