Between June 2022 and May 2023, Medicare reimbursed physicians for approximately 3.3 million intravitreal injections and 1.4 million claims for E/M services submitted with modifier -25 on the same day as an injection. On May 28, 2025, the Office of Inspector General (OIG) released an audit report on evaluation and management (E/M) services provided on the same day as intravitreal injections.1 It appears the findings from this report accelerated both audit activity and the release of additional guidance around appropriate use of modifier -25.
Q: Where is the recent scrutiny on modifier -25 coming from?
A: The scrutiny is coming from multiple sources, not just the OIG:
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The OIG audit (Report A-09-23-03014)
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The Supplemental Medical Review Contractor (SMRC) nationwide medical review project on modifier -252
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Updated guidance from the Centers for Medicare & Medicaid Services (CMS), including the latest Medicare Learning Network (MLN) Booklet “Evaluation and Management Services”3
Together, these efforts signal a coordinated focus on reducing improper payments related to modifier -25, particularly on claims filed with same day intravitreal injections.
Q: What were the results of the OIG’s report?
A: Between June 2022 and May 2023, the OIG found that providers used modifier -25 with 42% of intravitreal injections. For the audit, the OIG reviewed 24 claims across the 12 Medicare Administrative Contractor jurisdictions. Twenty-two of 24 claims (92%) did not satisfy requirements for modifier -25. The results align with prior OIG audits showing error rates of 100% and 78% for E/M services with same day injections.4,5
Q: Did the OIG make any recommendations?
A: Yes. The OIG recommended that CMS:
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Update Medicare requirements to clarify appropriate use of modifier -25.
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Conduct targeted medical reviews and recover improper payments.
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Provide additional education.
Q: What did the SMRC review find regarding modifier -25?
A: The SMRC conducted a broader, nationwide review of modifier -25 with same-day intravitreal injections. The results of the review showed a 30% error rate.
Q: What does CMS say in the latest MLN about modifier -25 and intravitreal injections?
A: The CMS MLN publication reinforces several key points that align with our historical understanding:
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Append modifier -25 when the E/M service is significant and separately identifiable from the minor procedure.
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The E/M service is beyond the usual preoperative and postoperative work associated with the injection.
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Payment for routine E/M services performed on the same date of service as a minor surgical procedure in the payment for the procedure.
However, CMS appears to have raised the bar by adding an example to the MLN Booklet that may conflict with historical guidance. The example suggests that appending modifier -25 to an E/M service on the same day as an injection requires both a new problem and a distinct management plan.
“For example, examining both eyes at the time of an injection to 1 eye isn’t a separately identifiable service. When you’re performing a pre-op exam, evaluate the patient’s fellow eye, and if that exam reveals a new diagnosis requiring a new management plan for a separately identifiable reason, we may consider [sic] it a separately identifiable service.”
Q: What does modifier -25 mean and how does it facilitate claim processing?
A: CPT defines modifier -25 as a “Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”6 Use modifier -25 when an office visit involves an exam that goes beyond the usual pre- and post-operative care associated with a minor procedure. According to the Medicare Claims Processing Manual (Chap 12§40.1(C)), “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.”7 When properly applied, modifier -25 allows the provider to receive separate reimbursement for the E/M service. Without -25, CMS bundles the exam with the minor procedure, resulting in a denial.
Q: What procedures are defined as “minor”?
A: CMS defines minor procedures as those with a zero- or 10-day post-operative period.8 Other than intravitreal injections (67028), other common minor procedures include sub-Tenon injections (67515), conjunctival and corneal foreign body removals (65205-65222), epilation (67820), laser trabeculoplasty (65855), punctal occlusion (68761), laser iridotomy (66761), pan retinal photocoagulation (PRP) (67228), etc.
Q: Is adding a second diagnosis enough to support modifier -25?
A: No, a second diagnosis alone does not justify using modifier -25. Modifier -25 identifies a medically necessary office visit that is unrelated to—or separately identifiable from—the pre- and post-operative work associated with the intravitreal injection. To support modifier -25, the documentation should include a medically necessary evaluation of an unrelated issue with an assessment/plan clearly addressing the separate problem(s). When these conditions are met, modifier -25 is likely supported.
Q: Does new patient status support modifier -25?
A: No. CMS clearly states that new patient status alone does not justify modifier -25.
Q: Is there a minimum time interval between visits to support modifier -25?
A: No. Time between visits is not a determining factor. Documentation of a separately identifiable E/M service supports appending modifier -25.
Q: If a full eye exam is documented, does that support modifier -25?
A: No. The extent of the evaluation is not a consideration.
A key question to ask:
If the patient were not receiving an intravitreal injection, would this visit still have occurred?
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If no → The exam is likely part of the procedure and not separately billable.
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If yes → Modifier -25 may be appropriate.
Both the OIG and the recent CMS MLN Booklet emphasize that routine pre-injection evaluations do not meet modifier -25 criteria.
Final Takeaway
The significant attention from various entities including the OIG, SMRC, and CMS reflect that:
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Modifier -25 is under significant scrutiny.
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The government believes that modifier -25 is not always applied correctly.
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Documentation must support a distinct, medically necessary E/M service.
With continued focus from CMS and its contractors, we encourage each practice to:
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Conduct internal reviews.
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Provide education to providers on the appropriate use of modifier -25.
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Establish documentation standards to ensure the medical record clearly supports a separately identifiable E/M service above and beyond the usual pre-operative and post-operative care associated with the procedure.
Taking these steps can strengthen compliance and reduce exposure. OM
References
1. Office of Inspector General, US Department of Health and Human Services. Medicare payments for evaluation and management services did not always comply with Medicare requirements. May 2025. Accessed April 10, 2026. https://oig.hhs.gov/documents/audit/10286/A-09-23-03014.pdf
2. Noridian Healthcare Solutions. Evaluation and management services error rates and findings. Noridian SMRC. March 12, 2026. Accessed April 10, 2026. https://noridiansmrc.com/completed-projects/01-146/
3. Centers for Medicare & Medicaid Services. Evaluation and management services guide. March 2026. Accessed April 10, 2026. https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
4. Office of Inspector General, US Department of Health and Human Services. Medicare payments for evaluation and management services—compliance review. March 2021. Accessed April 10, 2026. https://oig.hhs.gov/documents/audit/9575/A-09-19-03022-Complete%20Report.pdf
5. Office of Inspector General, US Department of Health and Human Services. Medicare payments for evaluation and management services—compliance review. September 2021. Accessed April 10, 2026. https://oig.hhs.gov/documents/audit/9577/A-09-19-03025-Complete%20Report.pdf
6. American Medical Association. Current procedural terminology (CPT). Accessed April 10, 2026. https://www.ama-assn.org/practice-management/cpt
7. Centers for Medicare & Medicaid Services. Medicare claims processing manual, chapter 12: physicians/nonphysician practitioners. July 24, 2025. Accessed April 10, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104C12.pdf
8. Centers for Medicare & Medicaid Services. Global surgery booklet. December 2025. Accessed April 10, 2026. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
