Evaluation and Management Services on Same Day as Minor Surgery With No Modifier 25

OBJECTIVE

Generally, Medicare reimbursement for an evaluation and management (E/M) service performed on the same day as a minor surgical procedure is included in the payment for the procedure.  However, Medicare makes an additional payment for a significant and separately identifiable E/M service provided on the same day as a minor surgical procedure.  To identify these significant and separately identifiable E/M services and bypass automated system edits, Medicare instructs physicians to append modifier 25 to the claim.  Analysis of Medicare paid claims data for E/M services provided by Part B providers during calendar years 2023 through 2025 identified payments for E/M services performed on the same day as a minor surgical procedure that were processed and paid without a modifier 25 appended.  We will determine whether the Medicare Administrative Contractors’ processing and payment of these E/M claims complied with Medicare requirements.

TIMELINE

• March 16, 2026
  Announced
• Today
  Office of Audit Services In-Progress
• Est FY2028
  Estimated Fiscal Year for Project Completion

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