Question

The director of coding and billing forwarded this memo to you, the medical insurance specialist, to help you plan for an internal audit.

Good Afternoon to All,

OIG today posts this report. As always, selecting the link immediately following the titles will take you directly to the full documents

Use of Modifier 25 (OEI-07-03-00470) www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

OIG conducted this study to assess the extent to which use of modifier 25 meets program requirements. Modifier 25 is used to allow additional payment for evaluation and management (E/M) services performed by a provider on the same day as a procedure, as long as the E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. OIG found that 35 percent of claims for E/M services allowed by Medicare in a single year did not meet program requirements, resulting in $538 million in improper payments. Modifier 25 was also used unnecessarily on a large number of claims, and while such use may not lead to improper payments, it fails to meet program requirements. OIG recommends that CMS work with carriers to reduce the number of claims submitted using modifier 25 that do not meet program requirements, emphasize that providers must maintain appropriate documentation of both the E/M services and

procedures, and remind providers that modifier 25 should be used only on claims for E/M services. CMS concurred with OIG's recommendations.

(1) What specific types of services will you audit?

(2) What specific codes or modifiers will you research? (3) When is it acceptable to use modifier 25?

Answer 1

What specific types of services will you audit?

It is the Medicare services and in particular concerning Modifier 25, which is defined as

"Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed." It is important to note that the use of Modifier 25 has to be with the appropriate level of E/M service.

What specific codes or modifiers will you research?

It is all about Modifier 25.

When is it acceptable to use modifier 25?

The following is reproduced from the narration given.

"emphasize that providers must maintain appropriate documentation of both the E/M services and procedures, and remind providers that modifier 25 should only be used on claims for E/M services. CMS concurred with OIG’s recommendations." Therefore the answer is The claims for E/M services only with appropriate documentation about the services and procedures related to the same.