Clinical Report: Coding & Reimbursement: Use and Abuse of Modifier -25

Overview

This report reviews the appropriate use of modifier -25 in ophthalmic claims, highlighting that it is reported in about 16% of office visits under Medicare. The Office of the Inspector General has raised concerns about the high usage rates and the need for proper application and documentation.

Background

Modifier -25 is critical for accurately billing for evaluation and management (E/M) services performed on the same day as minor surgical procedures. Misuse of this modifier can lead to significant compliance issues and financial repercussions for healthcare providers. Understanding the guidelines surrounding its use is essential for ophthalmologists to ensure proper reimbursement and avoid audits.

Data Highlights

No numerical data available.

Key Findings

• Modifier -25 should only be used for significant, separately identifiable E/M services on the same day as a minor surgical procedure.
• Ophthalmologists report modifier -25 on approximately 16% of all office visits, which may be excessive according to the Office of the Inspector General.
• Documentation must clearly support the need for modifier -25, distinguishing the E/M service from the minor procedure.
• Claims for E/M services performed on the same day as minor surgeries are bundled into the procedure payment unless they meet specific criteria for separate billing.
• CMS has intensified oversight of modifier -25 usage, particularly in relation to intravitreal injections.

Clinical Implications

Healthcare providers should conduct internal audits to ensure compliance with modifier -25 guidelines. Proper documentation and understanding of when to apply this modifier can prevent potential audits and financial penalties.

Conclusion

Adhering to the guidelines for modifier -25 is essential for ophthalmologists to ensure appropriate billing practices and avoid compliance issues. Continuous education and audits are recommended to maintain adherence to these standards.

Related Resources & Content

1. Mary Pat Johnson, Ophthalmology Management, 2026 -- Coding & Reimbursement: Use and Abuse of Modifier -25
2. OIG, Government Oversight, 2025 -- Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements
3. CMS, 2025 -- Medicare Claims Processing Manual
4. glaucoma physician — Understanding and Using Modifier -24
5. Ophthalmology Management — CODING & REIMBURSEMENT
6. Retinal Physician — CODING Q&A: Clarity Comes to Modifier 24
7. Understanding and Using Modifier -24
8. CODING & REIMBURSEMENT
9. https://www.cms.gov/files/document/2025nccimedicarepolicymanualcompletepdf.pdf
10. Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services
11. Dermatology Providers Generally Met Medicare Requirements for Evaluation and Management Services Performed on Same Day as Minor Surgical Procedures | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services