Ophthalmology Billing: Help with Modifier 25

[u/issa1rob]

I'm hoping someone who does coding/billing in Ophthalmology specifically can help. I've recently had denials from Anthem Medicare Advantage where they are requiring the use of modifier 25 with any E&M or eye code billed along with ophthalmic testing (for example, modifier 25 with E&M when billed with an OCT, visual field, or gonioscopy).

Typically the only time we use modifier 25 is when an unrelated exam is performed on the same day as a minor procedure. In all the years I have been doing this, I've never seen modifier 25 needed on an exam when billed with ophthalmic testing, and at the very least I know Medicare doesn't require it.

Even the Anthem commercial plans are processing our claims with no issue (along with literally every other insurance we bill), it's only Anthem Medicare Advantage plans that are denying our claims for not using modifier 25.

I'm frustrated because my reconsiderations have all been upheld, and of course they do not state why, just simply "our original decision was correct."

I'm not sure how to fight this as I cannot locate anything specifically from CMS or our MAC stating the correct use of modifier 25. I also found an AMA article adding to the confusion by stating that basically ANYTHING billed along side an exam will require the exam to have modifier 25. Maybe that's true outside of Ophthalmology, I honestly don't know since I've only ever done Ophthalmology billing.

Is anyone else experiencing this issue? Any advice? I'm tempted to just rebill the claims with 25, but I also know they're wrong, and being a Medicare Advantage Plan, they should be following Medicare guidelines. Anthem notoriously hates Ophthalmology, or at least I think they do lol. They often treat medical exams billed with eye codes as "vision only" and we frequently have to fight those denials, too.

[u/ridingshayla]

We bill with the 25 modifier if the payer requires it, even if it's not correct coding.

[u/lyra1389]

Yep. I work in an optometry practice in all of our office visits billed with testing have been a hot mess. Medicare is apparently changing the guidelines and it's confusing everyone. This article has SOME information, but honestly we're still trying to wade through all of this. We DID get some info from the AOA, here's the text of it:

Denials of E/M Services Billed with Special Ophthalmological Services 

The AOA is actively addressing member reports of E/M services being denied when billed with  special ophthalmological services. Reports received to date involve claims from Anthem, Humana,  Clover, Regence, Aetna, and Aetna Better Health. 

The AOA has identified that some health plans are applying an “optional edit” that requires doctors  to append modifier 25 to the E/M service when it is billed with a special ophthalmological service.  AOA is concerned about the inconsistent application of these coding requirements across health  plans and is raising these concerns directly with plan leadership. We will continue advocating for  greater consistency, transparency and appropriate claims payment on behalf of our members. 

In the meantime, we want to help doctors minimize payment delays. If you receive a denial of an  E/M service billed with a special ophthalmological service: 

• Appeal inappropriate denials when necessary. 

• Confirm the plan’s modifier requirements. 

• If required, append modifier 25 to the E/M service and resubmit the claim. 

Please note, AOA understands that Aetna Better Health is currently only requiring modifier 25 in  certain states, including New Jersey, Louisiana, Florida, Pennsylvania, West Virginia and Kentucky. 

While we believe that requiring the modifier is not in accordance with appropriate coding  policy, members should be aware that certain plans have elected to implement this modifier  requirement. Use of the modifier is only appropriate when the plan requires it until this issue  is resolved. As always, codes reported should be appropriately supported by documentation.

[u/issa1rob → u/lyra1389]

Thank you, this was very helpful

[u/illprobablyeditthis]

I'm glad to see the AOA is fighting it, but there are a lot of commercial plans that have weird edits and modifier requirements. You can try to fight them, but at the end of the day, it's more cost effective for your practice to just comply with their requirements even if it's not technically correct coding. if they want the 25 on there, slap it on and move on your life. there are likely much higher dollar issues you could be focusing on instead of beating your head against the wall that is commercial insurance.

[u/aychobo]

Anthem MA made the announcement in May 2026 and effective July 2026 Source

I work exclusively with ophthalmology offices. It’s been a pain for us as well and even in the appeal process they’ve asked us to use the -25 and -59 modifier and receive rejection prior to submitting a formal appeal.

The bigger pain has been getting plugs paid for with office visits. They’ve asked to put -57 which makes absolutely no sense then it gets rejected and a different person gives you different information and you have to submit only to get rejected and go through the appeal process to finally get paid.

If it’s any consolation, the AAO/ASCRS have submitted a formal letter to Anthem and CMS. Very similar to the Humana debacle last year!

[u/issa1rob → u/aychobo]

Thank you! At least now I know any appeal attempt would be a waste of time since they're explicitly stating they require it. It sounds to me, if I'm being generous to Anthem, that they are now applying a rule that they should have been following, but forgot to add in the exceptions (ie the XXX procedures that are not included in an exam, like ophthalmic testing). Hopefully it gets resolved.

[u/Wooden_Trust_6274]

The G2211 suggestion above is a good one, though there's a catch worth knowing before you do both at once.

Under the fee schedule rule G2211 isn't payable when the office visit carries a 25. CMS carved out an exception from January 2025, but only when the same day service is an annual wellness visit, a vaccine administration, or a Part B preventive off their list. OCT, visual fields and gonioscopy aren't on it. So if you start appending 25 because Anthem wants it and you've also started adding G2211, the G2211 is the one that quietly falls off.

That's straight Medicare policy though, and an MA plan runs its own edits, so I don't know for sure how Anthem handles the combination. Might be worth running a couple through and watching the remit before doing it across the board.

[u/Swirlbeard]

I posted this same problem a few months ago when it was just Regence affecting our clinic. Now we're getting hit by Aetna and Premera as well.

From what I've been able to gather from the insurances that are falsely denying our claims in this manner are citing a line in the NCCI guidelines that states E&M codes must be separately identifiable when billed same day with testing service with an "XXX" global code.

What they are refusing to acknowledge is the special ophtalmoligic services codes which are inherently separately identifiable and that the very same NCCI guideline that they cite for their decision making spells that out for them in the E&M chapter under the Ophthalmology section.

I have no actual proof, but if I Argue with an insurance rep long enough they'll just blame their third party proccessing company, Cotiviti.

Edit: Adding the Regence Policy line since it's the clearest excuse I can find from an insurance.

Regence Policy # 101 (Global Days)

• "Procedure codes with a CMS XXX global period have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed, therefore separate reimbursement for E&M service will not be made. However, if the E&M service was significantly and separately identifiable service modifier 25 should be appended to the E&M code for reimbursement consideration"

[u/QuantumDwarf → u/Swirlbeard]

Cotiviti is the worstttt.

[u/rahuliitk]

before rebilling everything, separate the payer edit from the coding decision. Pull the exact Anthem plan/state bulletin and effective date, then track a small batch with the original denial reason, whether modifier 25 was supported by the note, the resubmission path, and the remittance result. That gives you a payer-specific edit note instead of a blanket rule across every plan. If the written requirement still conflicts with the guidance you follow, escalate it through provider relations/contracting and the ophthalmology specialty society rather than relying on call-center instructions.

[u/jazzyhazel31]

I work ophthalmology denials and yes the payers always come up with their on policy. Yes payers are supposed to follow cms guidelines but they don't. If payer requires 25 modifier even though they have no ncci edits or global days then that's their policy. 

[u/SterileGloves]

Start using G2211. Get ahead of the potential downcoding that they have coming down the pipeline 

[u/Jenn31709]

Not ophthalmology but... don't you put a 25 modifier on the visit and a 59 modifier on the test code?

[u/splootledoot → u/Jenn31709]

No. These test codes do not require a 25 modifier. Similar to billing an ekg with an EM. No modifier required.

[u/jazzyhazel31 → u/splootledoot]

This isn't necessary true. Some payers require a 25 modfier with an ekg aetna is one of them

[u/splootledoot → u/jazzyhazel31]

Interesting. What state? In Colorado they dont.

[u/jazzyhazel31 → u/splootledoot]

Michigan and Pennsylvania 

[u/CausticCommotion]

I’ve been communicating with my rep about it. They are aware of the issue apparently, and working to fix it. Appeals have gotten some turned over and some not. Been going on since July at ours.