Using modifier 25 will often get your exam claim paid — but know when to use it correctly.

Are you allowed to bill for an eye exam on the day of a minor surgical procedure? If you haven’t looked at this question lately, you may be surprised. Using modifier 25 will often get your exam claim paid — but know when to use it correctly.

Q. What is modifier 25?

A. CPT defines modifier 25 as a “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It indicates that the patient’s condition required an exam (E/M or eye code) beyond the usual preoperative care provided for the procedure or service. CPT language emphasizes the importance of charting. It states, “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”

CPT adds that “This modifier is not used to report an E/M service that resulted in a decision to perform surgery.”

Q. What types of procedures or services require the use of modifier 25?

A. Append modifier 25 to an exam (992xx or 920xx) when a separately identifiable service has been performed on the same day as a minor procedure. Medicare defines minor procedures as those with zero or 10 days of postoperative care. Examples include foreign-body removal (65222), laser trabeculoplasty (65855), epilation of lashes (67820) and intravitreal injection (67028).

Q. Must we have more than one diagnosis on the claim to use modifier 25?

A. The CPT definition of modifier 25 states, “... different diagnoses are not required for reporting of the E/M services on the same date.” If more than one problem is being addressed at the visit, report the appropriate diagnoses on the claim.

Even when there is only a single diagnosis, the exam may be billable. The CPT definition says that a separately identifiable service must be provided. A separately identifiable exam is reimbursable in addition to the procedure when the physician has to cope with more than one occurrence (eg, right eye vs left eye) of the same problem in different ways.

Q. When is the use of modifier 25 not appropriate?

A. If the only purpose of the exam is preoperative care, then a claim for an office visit with modifier 25 would not be appropriate. Without an unrelated diagnosis, most office visits will not meet the modifier 25 definition. The same-day exam is rarely anything but the usual preoperative work. In situations as noted above, the same diagnoses may support both an office visit and a minor procedure on the same day.

Q. Does use of modifier 25 affect the value ascribed to the exam?

A. Not for Medicare or most payers. In general, use of modifier 25 makes full reimbursement of both the office visit and the minor procedure possible. Without it, the exam may be denied as preoperative work. A few payers have indicated that use of modifier 25 will reduce the allowance for the exam, although we have not seen it yet.

However, it is critical to remember that elements of the exam (for eye codes) or the medical decision making (for E/M codes) that are related to the minor procedure cannot count toward selecting the exam code. This may very well affect the level of service for the exam.

Q. Will the use of modifier 25 attract attention from Medicare?

A. Excessive use of this modifier may garner unwanted attention. A November 2005 report (OEI-07-03-00470)¹ released by the Office of Inspector General (OIG) indicated that 35% of 2002 claims with modifier 25 did not meet program requirements. OIG recommended that CMS work with Medicare Administrative Contractors to reduce inappropriate claim submission with modifier 25. Recovery audit contractors (or RACs) are also closely scrutinizing the use of modifier 25.

In our analysis of CMS data, we find that about 13% of exams were associated with modifier 25 in 2018. That is, for every 100 office visits reimbursed to ophthalmologists in 2018, 13 were billed with modifier 25. If your utilization significantly exceeds this amount, scrutiny from Medicare is likely.

Q. What is the best way to document a minor procedure?

A. The exam and minor surgery may appear on the same page in the medical record, but we don’t recommend it.

We suggest creating a complete note for the office visit, including a complaint, pertinent exam elements, impression and plan related to the condition not associated with the minor surgery.

A separate operative report is needed for the surgery. Include indications for the procedure, a description of the procedure and discharge instructions. A Minor Procedure Operative Report template² is available for download at no charge on our website. A clearly documented consent for the procedure should also be included, either written or verbal. OM

REFERENCES

1. U.S. Department of Health and Human Services; Office of Inspector General. Use of modifier 25. Nov. 2005. https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf . Accessed Sept. 1, 2022.
2. Corcoran CCG. Minor procedure operative report. https://www.corcoranccg.com/products/forms/operative-report-forms/minor-procedure-operative-report/ . Accessed Sept. 6, 2022.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .