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Ophthalmology Management

Article

Coding & Reimbursement: Use and Abuse of Modifier -25

Review the guidance and conduct an internal audit to confirm that your providers and staff are applying this modifier appropriately.

By: Mary Pat Johnson, COMT, CPC, COE, CPMA
Ophthalmology Management January 9, 2026

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

At a Glance

CategoryDetail
Condition
Key Mechanisms
Target PopulationOphthalmology providers, billing staff, and administrative personnel
Care Setting

Key Highlights

  • Modifier -25 is used for significant, separately identifiable E/M services on the same day as a minor procedure, not applicable to all minor procedures.

Guideline-Based Recommendations

Diagnosis

    Management

    • Conduct internal audits to ensure appropriate application of modifier -25, focusing on documentation and justification.

    Monitoring & Follow-up

      Risks

        Patient & Prescribing Data

        Modifier -25 can be appended to E/M services when addressing unrelated issues, such as new symptoms or conditions during the same visit.

        Clinical Best Practices

        • Thoroughly document all conditions addressed during the office visit, including unrelated issues.
        • Ensure that the office visit is distinct and extends beyond the decision for surgery.
        • Use modifier -25 judiciously, only when criteria are met, and train staff on documentation standards.

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