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    OIG still cracking down on use of modifier 25

    Q. I keep hearing about how the Office of the Inspector General (OIG) is cracking down on modifier 25 claims.

    I am curious to know what this means and what I need to do to stay within the boundaries of compliance.

    You are correct. The OIG has put modifier 25 on its “hit list” after determining that related claims have significant error rates and that the modifier has been used inappropriately and indeterminately on as many as 35% of submitted claims. Even though you saw the patient in the urgent care facility, it has a different tax ID number; as you mentioned, you have no access to the patient record.

    Modifier 25 is defined as a “significant, separately identifiable evaluation and management [E/M] service” by the same physician on the day of a procedure. For example, a patient comes in for routine foot care. On the same day, he or she also undergoes a significant, separately identifiable service in addition to the foot care. Rules allow modifier 25 to be appended to the E/M, but the procedure must be classified as medically necessary. The modifier indicates that the service was above and beyond the routine procedure for which the patient made the appointment.

    Medical practices, for better or worse, have learned that randomly using modifier 25 could be an easy way to get claims paid. The Centers for Medicare and Medicaid Services have caught on to this practice and are working with the OIG to monitor incorrectly paid claims in an attempt to recoup this money from providers.

    An instance of an inappropriate use of modifier 25 could occur when a patient visits the office for a minor procedure only, but the visit is billed with a modifier 25 on the E/M. Because the visit was explicitly for a minor procedure, this billing would be considered inappropriate and could be flagged by the OIG for recoupment proceedings.

    Education within your practice is a must to keep the OIG from showing up on your doorstep. To avoid recoupment action, follow these steps when using modifier 25 in claims:

    • Always append to the E/M code, if appropriate.

    • Never append to a procedure code.

    • If special tests are performed on the same day as an E/M, then do not append modifier 25 to the E/M.

    • Run frequent utilization reports, and perform regular audits on modifier 25 usage.


    The author is an associate director at SS&G Healthcare, Akron, Ohio. Send your primary care-related coding question to [email protected]. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.

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