Modifier -25

The Academy agrees that clear, specific guidance from CMS on modifier -25 is needed. However, we are concerned that the Office of the Inspector General (OIG) extrapolated findings from a small sample to make broad generalizations about compliance across the field. It is unfair to penalize practices when current CMS guidance is inadequate.

The Academy opposes audits of modifier -25 usage until CMS issues guidance specific to evaluation and management visits billed on the same day as intravitreal injections. Notably, the Noridian Supplemental Medical Review Contractor (SMRC) audits that followed the OIG report found an error rate of just 7% — far lower than the OIG report suggested — which underscores the Academy's concern that the original findings were not representative. 

The Academy and the retina specialist community have advocated for clear modifier -25 guidance from CMS for more than a decade, including letters to the agency in 2012, 2014, and 2018, and a 2013 meeting with CMS's Provider Payment and Program Integrity team.

Following the May 2025 OIG report, the Academy and the American Society of Retina Specialists (ASRS) met with the OIG's Office of Audit Services and with Noridian's SMRC program to present the Academy's coding guidance and share member concerns.

Through persistent outreach, the Academy — together with ASRS and the American Medical Association — secured a meeting with CMS's Division of Practitioner Services staff on April 9, 2026 to discuss our concerns regarding confusing and inconsistent language in the agency’s Medicare Learning Network (MLN) resources. CMS was receptive to our feedback and removed the problematic language in June 2026. We remain committed to partnering with the agency to ensure policies that support appropriate coding, reduce administrative burden, and protect timely access to high-quality vision care for Medicare beneficiaries.

The Academy will continue to monitor this issue closely. Visit aao.org/modifier25 for the latest updates and recommendations. 

The Academy encourages all practices that bill modifier -25 to take the following steps:

• Continue practice-wide coding education to ensure consistent understanding of modifier -25 requirements
• Conduct internal chart audits to identify and address documentation gaps before external auditors do
• Enhance documentation standards to clearly support the medical necessity of same-day E/M visits
• Monitor aao.org/modifier25 regularly for Academy updates, guidance, and recommendations

Modifier -25 is used to indicate that a patient's condition required a significant, separately identifiable E/M service on the same day as a procedure — in this context, an intravitreal injection. Ophthalmologists routinely evaluate patients before administering injections to treat conditions such as wet age-related macular degeneration and diabetic macular edema, and a separate E/M service can be medically warranted and appropriately billed.

In May 2025, the Department of Health and Human Services Office of Inspector General released a report finding that 22 of 24 reviewed E/M services billed with modifier -25 alongside intravitreal injections did not meet Medicare requirements. The OIG made three recommendations to CMS: clarify modifier -25 guidance specific to intravitreal injections, conduct medical reviews of these services, and provide targeted provider education. CMS agreed with the medical review recommendation and pointed to prior education efforts dating to 2018 — though the OIG noted that none of those resources are specific to E/M services billed with intravitreal injections.

Following the report, CMS updated the Evaluation and Management Services Medicare Learning Network Booklet (MLN006764) in September 2025. In the Academy's view, this update made the agency's guidance more confusing rather than less. As a result of persistent advocacy by the Academy, ASRS, and the AMA, CMS removed the confusing language from the MLN in June 2026. CMS also instructed Noridian, the Supplemental Medical Review Contractor, to audit established patient eye visit codes billed with modifier -25 on the same day as an intravitreal injection for dates of service June 1, 2022, through May 31, 2023. Those audits concluded in March 2026 and showed an error rate of just 7% — a result the Academy believes reflects the appropriateness of how ophthalmologists are billing these services.