Modifier Code 25 - Vision

Important Note:

HMSA has partnered with EyeMed, service date effective January 1, 2022. HMSA transitioned our current vision portfolio to a new vision benefit with EyeMed for the following line of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees. HMSA will continue to be the administrators for non-routine vision services through the members medical plan(s). For more information, please contact EyeMed at www.eyemedinfocus.com

Contact by phone:
For Providers 1-888-259-4344

Modifier code 25 should be used to identify significant, separately identifiable evaluation and management services (E/M) performed by the same physician on the same day as a procedural service. E/M services may only be billed with procedural services when the patient's medical condition requires services beyond those normally provided with the procedural services, or beyond the usual pre-operative and post-operative care normally associated with the procedural services.

Modifier code 25 should not be used to report an E/M service resulting in a decision to perform major surgery. In this case, modifier 57 should be used.

Example

An established patient goes to see his optometrist because two days previously a passing truck caused a small piece of gravel to fly into his right eye. The patient tried to wash it out and rub it out, but was unsuccessful. The patient came in because the eye was still irritated and tender and was now very red. Upon examination the optometrist found that the patient had a purulent discharge and conjunctival irritation in addition to a piece of sand that he removed from the conjunctiva.

Due to the complexity and amount of medical decision-making involved with this visit, the provider may bill an E/M visit, using modifier code 25, in addition to the procedure.

The provider's services would be represented on the CMS 1500 claim form as follows:

Diagnoses shown in block 21:

ICD-9-CM:

1. 372.03
2. 871.6
3. E914

ICD-10-CM:

1. H10.021
2. S05.51xA
3. T15.11xA

In addition, the procedures and diagnoses would be linked in section 24 as follows:

Claims Filing Information

When billing an E/M service with modifier code 25, list all applicable diagnoses in Block 21 of the CMS 1500 claim form. Be sure that each service listed in column 24D is linked with the appropriate diagnosis indicator in column 24E. However, please keep in mind that although a chronic condition may be listed on the claim (as in example 3), modifier 25 should not be used unless the physician is providing active treatment or medical management of the condition during the same visit.

Effective July 1, 2004, except as otherwise indicated below, claims with modifier code 25 may be submitted via EMC and supporting documentation will not be required.

Certain practitioners may be asked to continue submitting claims in a hard-copy format with a copy of the physician’s clinical notes for the date of service attached. Physicians who are asked to submit hard-copy claims with documentation will receive written notification of this requirement from HMSA. If you are asked to submit your modifier 25 claims with documentation, please be sure the patient’s name, HMSA member ID number, and the date of service appear on the attachment as well as on the claim. The documentation should clearly indicate that a separately identifiable service was performed in addition to the services normally provided with the procedural service. These notes will help HMSA staff determine that modifier code 25 has been used appropriately.

Review

HMSA reserves the right to perform either prepayment or postpayment review as needed to verify that modifier 25 is used in accord with this policy. Under the provisions of the privacy regulations of HIPAA, medical records may be used to verify correct payment.

If prepayment review findings indicate use of modifier 25 that is not in accord with this policy, payment will not be made for the E/M service.

If postpayment review findings indicate use of modifier 25 that is not in accord with this policy, HMSA will take steps to recover any overpayment.

Revision History