The use of modifier -25 to claim reimbursement for an exam on the day of a minor procedure continues to increase. Postpayment audits of modifier -25 have increased, too. Let’s review what you need to know.
Q. What does modifier -25 mean?
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 minor procedure performed. CPT adds, “This modifier is not used to report an E/M service that resulted in a decision to perform surgery.”
According to Medicare, 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-day or 10-day global periods). The American Academy of Ophthalmology finds many practices are under the impression that modifier -25 may be associated with minor procedures in the same way that modifier -57 is associated with a decision for a major surgery and emphasizes, “The answer is no. Modifier -25 does not indicate it is the visit to determine the need for a minor surgery.”
AAO 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.”2
Also, according to CMS, “... 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.”3
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. What are common minor procedures?
A. In retina, the most common minor procedure is intravitreal injection (67028). Panretinal photocoagulation (PRP, 67228) is also a common retinal procedure. There are others.
Q. Isn’t an eye exam essential prior to the intravitreal injection? How are physicians paid for it?
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. Excessive use of this modifier may indeed garner unwanted attention. A report by the Office of Inspector General (OIG) indicated that 35% of 2002 claims with modifier -25 did not meet program requirements;4 we believe this is still true and may have gotten worse. As a result, Medicare contractors and other third-party payers are working to reduce inappropriate claim submission with modifier -25.
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: H35.323-) in both eyes. During today’s exam, you evaluate both eyes but inject only the left eye (ICD-10: H35.322-). 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. How often should we use modifier -25?
A. Within the Part B Medicare program, 13% of all eye exams performed by ophthalmologists (all subspecialties) are associated with modifier -25. In 2018 (the most recently available data), retina specialists performed more than 3.6 million intravitreal injections. Based on chart reviews performed by Corcoran’s certified professional medical auditors, only about a quarter of all intravitreal injections were associated with an exam for an unrelated reason that justified modifier -25.
Q. Does the use of modifier -25 affect the value ascribed to the exam?
A. No. Use of modifier -25 makes full reimbursement of both the office visit and the minor procedure possible. Without it, the exam would be considered preoperative and not be paid at all. RP
- American Medical Association. 2020 Current Procedural Terminology, Professional Edition. American Medical Association; 2020.
- American Academy of Ophthalmology Coding Bulletin; November 2012.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual Chapter 12 §40.2.A4. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912 . Accessed June 12, 2020.
- US Department of Health and Human Services Office of Inspector General. Report OEI-07-03-00470; November 2005. https://tinyurl.com/y8tfmejl . Accessed June 12, 2020.