The chief complaint is the starting point for every evaluation and management (E/M) service. Although history, exam, and medical decision making ultimately determine the level of service, the chief complaint establishes the purpose of the encounter. Palmetto clarifies: “A chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service. The extent of the information gathered for the CC and history component is dependent upon clinical judgment and the nature of the presenting problem. The documentation must clearly reflect the CC.”¹

For auditors—including the Office of Inspector General (OIG) and various review contractors—this initial statement is frequently the first indicator of whether the office visit is separately payable or instead bundled into global surgical care or part of the preprocedural examination process. When the chief complaint is vague or limited to postoperative or a planned procedure without any indication of an unrelated problem needing medically necessary evaluation, supporting additional E/M reimbursement with modifiers -24 or -25 becomes difficult. Establishing medical necessity through the chief complaint can directly influence whether a claim passes an audit review. 

Purpose of the Examination Drives Coverage

Medicare has long emphasized that coverage for an examination is determined by why the patient is being seen, not what is ultimately found during the encounter. CMS Transmittal 1802² states:

“The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient’s condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to an ophthalmologist for an eye examination with no specific complaint, the expenses for the examination are not covered even though the doctor discovered a pathologic condition.”

In other words, the chief complaint drives medical necessity for the examination and sets the stage for whether an encounter is billable.

Why the Chief Complaint Matters for Office Visits With Modifiers -24 and -25

These modifiers allow billing of an office visit when there otherwise would not be reimbursement due to global surgical periods or procedural bundles. Novitas’ fact sheet³ indicates that “Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period.” The same fact sheet states that, “Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.”

Noridian’s fact sheet⁴ states that Modifier -25 is used “to indicate that an E/M service or eye exam, performed on same day as a minor surgery (000 or 010 global days) and performed by the surgeon, is significant and separately identifiable from usual work associated with surgery.” Noridian goes on to say that the E/M service “must have a history, exam and medical decision making (HEM). All procedures include some service related to patient evaluation and management. A separate E/M should include its own HEM. Physician must determine whether problem is significant enough to require additional work to perform key components of problem oriented E/M service.”

In both circumstances, whether the E/M service is billable begins with a simple but critical question: What does the chief complaint tell us about why the patient is being seen today? If the chief complaint appears solely tied to the postoperative care or the minor procedure, modifier use becomes more difficult to defend.

How Do We Document for Success?

In postoperative encounters, whether a visit is considered routine global care or a separately billable, medically necessary E/M service depends on the documented reason for the visit. Consider a patient who had cataract surgery on their left eye a week ago and is now being seen for new floaters in the nonsurgical right eye. Medical necessity for the new, unrelated problem should be clearly established first, with postoperative status documented as a secondary reason for the visit.

For example:

• CC/HPI 1: Patient complains of new floaters OD x 3 days.

• CC/HPI 2: Patient is s/p cataract surgery ~1 week ago, no complaints.

In contrast, if the chief complaint only states “patient here for 1 week post op visit,” it does not establish medical necessity to evaluate the nonsurgical eye, making modifier -24 difficult to defend.

The same principles apply to same-day minor procedures, such as intravitreal injections or punctal plugs. When a patient presents for a scheduled minor procedure but also has a new or significant condition that is medically necessary to be evaluated on the same date of service, the chief complaint should reflect that.

For example:

• CC/HPI 1: Patient complains of new distortion and decreased vision OD for 1 month. Patient with history of epiretinal membrane OD.

• CC/HPI 2: Patient is also scheduled for punctal plugs OU today.

Without a documented, medically necessary complaint beyond the reason for the minor procedure, a separate E/M service with modifier -25 is likely not supported.

In Practice

The chief complaint helps establish medical necessity for the office visit. In ophthalmology, where minor procedures and global periods are common, the chief complaint helps determine whether an E/M service is supported and separately reimbursable. Medicare guidance reinforces that coverage is based on the purpose of the encounter, not the ultimate findings.

Accordingly, medical necessity for an office visit must be established at the onset through a clear, specific chief complaint. When the complaint reflects a significant, separately identifiable problem or an unrelated condition addressed during the global period at a medically necessary interval, an office visit with modifier -24 or -25 may be supported.

As regulatory scrutiny increases, it is essential that documentation clearly supports the medical necessity for the office visit, especially during a global period or on the same day as a minor procedure. A well-defined chief complaint helps support defensible documentation and protects practices from denials and potentially lost revenue. OM

References

1. Palmetto GBA. E/M Weekly Tip: Chief Complaint. Published August 3, 2020. Accessed June 12, 2026. https://tinyurl.com/49bcs8dj

2. Centers for Medicare & Medicaid Services. Revisions to payment policies under the physician fee schedule and other Part B payment policies for CY 2010. Transmittal 1802. August 28, 2009. Accessed June 12, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1802b3.pdf

3. Novitas Solutions. Evaluation and management FAQs. Published January 2023. Accessed June 12, 2026. https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00101583

4. Noridian Healthcare Solutions. Modifier 25. Accessed June 12, 2026. https://med.noridianmedicare.com/web/jeb/topics/modifiers/25

Brittney Irwin, COT, CPC, CEP, is a senior auditor with VMG Health (formerly BSM Consulting) in Durango, Colorado. She has experience in the ophthalmic industry holding managerial and clinical roles for more than 14 years.

Laurie K. Brown, MBA, COMT, COE, CPC, CPMA, LSSYB, is a director with VMG Health (formerly BSM Consulting) in Tucson, Arizona. She has experience in the ophthalmic industry holding managerial, clinical, and surgical roles for more than 35 years.