Here we are, again, talking about the use of modifier -25 on ophthalmic claims for reimbursement. Within the Medicare program, ophthalmologists report this modifier on about 16% of all office visits. The Office of the Inspector General thinks that may be too high. Their September 2025 Medicare Learning Network booklet1 discusses the minor-surgery billing rules and when billing a same-day office visit with the use of modifier -25 is appropriate. While the discussion focused on intravitreal injections, the guidelines apply to minor surgeries in general.
CMS has been monitoring claims and has conducted numerous investigations of providers with a higher-than-expected use of this modifier for many years. There have been a few significant settlements.
This is a good time to review the guidance and perhaps conduct an internal audit to confirm your providers and staff are applying this modifier appropriately. In short, it should be used to identify a billable office visit performed on the day of a minor surgery.
What is Included in the Payment for a Minor Surgery?
The global surgery package concept applies to minor procedures and includes:
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Preoperative visit on the day of surgery
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Postoperative visits related to recovery
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Some supplies such as a surgical tray
Services not included in the global surgery package2 are:
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Same day examination when a separately identifiable service is performed
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Diagnostic tests and procedures, including diagnostic radiological procedures
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Postop visits unrelated to the diagnosis for which the surgical procedure is performed
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Distinct surgical procedures that are not re-operations or treatment for complications
Medicare’s NCCI policy manual3 contains information on exams performed on the day of a minor surgery. While the discussion references E/M services, the same instructions apply when an eye exam code (CPT 92002 – 92014) is used:
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If a procedure has a global period of 0 or 10 days, it’s defined as a minor surgical procedure.
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In general, E/M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. This includes the decision to perform a minor surgical procedure; do not report it separately as an E/M service.
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A significant and separately identifiable office visit, unrelated to the decision to perform the minor surgery separately reportable with modifier 25.
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The E/M service and minor surgical procedure don’t require different diagnoses.
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The same rules for reporting E/M services apply when a minor surgical procedure is performed on a new patient.
An office visit to address a problem other than the one leading to the minor procedure will be the exception that justifies a claim for reimbursement.
How is Modifier -25 Defined?
The full definition in CPT4 reads: Significant, separately identifiable evaluation and management service by the same physician or other qualified care professional on the same day of the procedure or service.
The CPT manual goes on to describe the services as: above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.
What Makes an Office Visit “Separately Identifiable”?
This requirement is met when the office visit is substantial, distinct, unique, and stands alone. It distinguishes itself from the minor procedure because it extends beyond the typical preoperative work. This may entail examination of other organ systems, examination of the opposite side of the body from the affected area, evaluation of a combination of symptoms that suggest numerous problems, or other concurrent treatments besides the minor procedure. The Medicare Claims Processing Manual illustrates this as such:
For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.3
What Documentation Is Necessary to Support the Claim With Modifier -25?
Charting should include a thorough description of the encounter, all conditions addressed, and treatment options considered. Documentation of the initial chief complaint and history can set the stage. Note all the reasons the patient is being seen. This may include the scheduled reason as well as any new symptoms or complaints the patient describes.
Throughout the encounter, the scribe or physician charting the exam should take care to document if, and how, all the conditions were addressed. At the conclusion of the note, if there is enough documentation to support an unrelated, separately identifiable exam that is above and beyond the decision to proceed with the minor surgery, an eye exam charge is likely warranted.
Case Study With a Solitary Diagnosis
Your patient returns for a glaucoma follow-up exam. After examining the patient and noting primary open-angle glaucoma with elevated intraocular pressure OU, the physician recommends selective laser trabeculoplasty OU. The laser procedure is performed on the right eye today. Due to travel plans, the patient cannot return for the procedure in the left eye for 1 month. A prescription is given for a different eye drop to be used OS and the patient is scheduled for a follow up in 1 month.
Bill for the laser procedure performed on the right eye and the exam to assess and manage the glaucoma in the left eye. Append modifier -25 to the exam charge.
Case Study With Multiple Unrelated Diagnoses
Your patient presents for a follow-up of mild, chronic, open-angle glaucoma OU, and complains of a new foreign body sensation OD x 1 day. Upon exam, a small foreign body is found in the palpebral conjunctiva RLL, and there is a faint corneal abrasion. The foreign body is removed at the slit-lamp. The bilateral glaucoma is stable. The patient is instructed to continue glaucoma drops. Add artificial tears OD if the foreign body sensation persists.
Bill for the foreign body removal performed on the right eye and the exam to assess and manage the glaucoma in both eyes. Append modifier -25 to the exam charge.
Case Studies Without Separately Identifiable Exams
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Your established patient was seen 3 weeks ago to evaluate a bothersome lid lesion that often turns red and bleeds. She presents today for the removal.
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Your patient with cicatricial pemphigoid was last seen 4 weeks ago to address recurrent trichiasis. Examination today found persistent trichiasis. Several eyelashes are epilated from both eyes.
In these cases, bill only for the minor surgery procedure.
Conclusion
Keep in mind these essential points:
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Modifier -25 should not be associated with every minor procedure. It is the exception, not the rule.
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Modifier -25 is appended to E/M or eye codes, not to a minor procedure code.
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The office visit addresses another problem than the one for which the minor procedure is performed, not necessarily a different diagnosis. It represents more than the decision for surgery. It extends above and beyond preoperative care. OM
References
1. American Medical Association. Medicare Learning Network Booklet MLN006764. September 2025. www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
2. American Medical Association. Medicare NCCI Policy Manual. (Chapter 1, Section D). www.cms.gov/files/document/01-chapter1-ncci-medicare-policy-manual-2025finalcleanpdf.pdf#page=12
3. American Medical Association. Medicare Claims Processing Manual (Chapter 12, §40.1 B). www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
4. American Medical Association. CPT 2025 Professional Edition. American Medical Association; 2025.
