A recent federal audit revealed many claims lack supporting documentation for evaluation and management (E&M) services billed with modifier 25 when provided on the same day as an eye injection (i.e., intravitreal injection), emphasizing the need for proper use and documentation.
Modifier 25 is “defined as a significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of a procedure or other service,” according to Novitas Solutions, the Medicare administrative contractor overseeing Texas.
Using modifier 25 indicates the patient’s condition required a significant, separately identifiable E/M service that is above and beyond the work normally associated with the procedure performed and lets the payer know the separately identifiable E&M service was addressed on the same day.
The May 2025 U.S. Department Health and Human Services’ (HHS’) Office of Inspector General (OIG) report, citing prior OIG audits and the OIG’s Office of Audit Services’ recent audit of Medicare payment for certain eye injections, found that billing for nearly half of the procedures used modifier 25 in tandem with E&M services. In the most recent audit, of the 24 sampled E&M services billed with modifier 25 and provided on the same day as intravitreal injections using the modifier, 22 were found to be improper, as the use of modifier 25 was not supported by documentation.
OIG recommended in the report that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to promote better understanding of how to bill using modifier 25.
In light of the report, TMA staff offer the following modifier 25 tips:
- Append modifier 25 to the E&M code (reported to the appropriate level), not to the procedure code.
- Don’t report a separate E&M service for a planned procedure.
- Ask yourself, does the documentation support a significant, separately identifiable E&M service? If not, modifier 25 is not appropriate.
Physicians with these and other billing and payment questions can contact TMA’s Physician Payment Resource Center.
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Last Updated On
February 04, 2026
Originally Published On
February 04, 2026
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.