Clinical Report: Modifier -25 Scrutiny for Same-Day E/M Services

Overview

Revise to include the source of the audit findings and implications of the 92% error rate.

Background

The appropriate use of modifier -25 is critical for ensuring that healthcare providers receive proper reimbursement for evaluation and management (E/M) services performed on the same day as minor procedures like intravitreal injections. Increased scrutiny from the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) highlights the need for compliance with billing regulations to prevent improper payments.

Data Highlights

Key Findings

• 42% of intravitreal injections were billed with modifier -25.
• 92% of claims reviewed by OIG did not satisfy the requirements for modifier -25.
• The SMRC reported a 30% error rate in its nationwide review of modifier -25 usage.
• CMS has updated guidance emphasizing that modifier -25 requires a significant, separately identifiable service.
• Modifier -25 should not be used based solely on new patient status or time between visits.

Clinical Implications

Healthcare providers must ensure that documentation for same-day E/M services clearly demonstrates that the service is significant and separately identifiable from the procedure. This will help avoid denials and ensure compliance with Medicare requirements.

Conclusion

The scrutiny surrounding modifier -25 usage underscores the importance of accurate billing practices in ophthalmology, necessitating ongoing education and adherence to updated guidelines.

References

1. Office of Inspector General, 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
2. Optometric Management, 2022 -- BUSINESS: Coding Strategy
3. Ophthalmology Management, 2016 -- Coding & Reimbursement
4. Ophthalmology Management, 2023 -- Coding & Reimbursement
5. Diabetic Retinopathy Preferred Practice Pattern® - PubMed, 2025
6. Ophthalmology Management — Coding & Reimbursement: Separate Procedures and NCCI Bundles
7. Diabetic Retinopathy Preferred Practice Pattern® - PubMed
8. 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