Appropriate use of modifier 25

From AOA's Coding Experts Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.

In 2015, the AOA reported on a report by the Of­fice of the Inspector General (OIG) for the U.S. Department of Health and Human Services on billing for "ophthalmology services." The OIG report sought to determine the extent to which ophthalmology services are vulnerable to fraud, waste and/or abuse. It is important to be aware of the ­findings of this report as the broad category of "ophthalmology services" includes many of the procedures provided by doctors of optometry, and the report includes some speci­fic data on billing by doctors of optometry.

Overall, the OIG report found that most eye care physicians did not exhibit questionable billing practices. However, the report did provide some data indicating that certain doctors of optometry are billing claims with modifiers 24 and 25 at a higher rate than other eye care providers.

In 2020, appropriate use of Modi­fier 25 continues to come under scrutiny by auditors and the OIG. A recent OIG settlement with an ophthalmology practice resolves "allegations that the practice improperly used the Modi­fier 25 billing code to charge Medicare and Medicaid for exams that were not separately billable from other procedures performed on the same day. The settlement also resolves allegations that certain Medicare and Medicaid billings during the same period included charges for exams at higher levels than appropriate." It is important to note that the claims settled by this agreement are allegations only; there has been no determination of liability.

All doctors should understand the appropriate use of Modi­fier 25 as outlined below.

Modi­fier 25

• Modi­fier 25 is of­ficially de­fined as "a signi­ficant evaluation and management (E/M) service by same physician on date of global procedure." This means if E/M services are provided that exceed what is normally involved in preparing a patient for a procedure and the standard follow-up services directly following a procedure, then an E/M service should be reported along with Modi­fier 25.
• It's important to recognize that many of the elements of an E/M service are included as a standard part of performing surgical services. For example, during a foreign body removal, obtaining the patient's ocular and general medical history; performing an external exam; evaluating distance vision; and a slit lamp examination would all be standard procedures performed prior to the foreign body removal.
• However, it is possible for additional E/M services to be necessary when performing surgical services. For example, if a patient presented for treatment of glaucoma and in the course of treating the patient the doctor identi­fied a foreign body, the evaluation for glaucoma and the foreign body removal would be reported. The E/M would be reported with Modi­fier 25.
• Modi­fier 25 should only be used when reporting E/M services.
• Documentation must reflect the necessity of the E/M service.
• Doctors of optometry should be aware that an E/M service that is provided on the day of procedure with a global fee period will only be reimbursed if the physician indicates that the service is for a significant, separately identi­fiable E/M service that is above and beyond the usual pre- and postoperative work of the procedure.