Introduction
The OIG has identified the following trends in modifier 25 errors:
Modifier 25 should not be used on claims that have been denied by Medicare or have been adjusted to zero. Fewer than 20 percent of modifier 25 claims are correct. Overuse of modifier 25 has increased significantly since 2009. Most modifiers 25 used incorrectly were billed inappropriately by physicians, hospital outpatient departments (HOPDs), or outpatient surgery centers (OSCs).
The use of modifier 25 is a problem, but it can be corrected if providers are aware of the rules around it.
The OIG Has Identified The Following Trends In Modifier 25 Errors:
- Modifier 25 should not be used on claims that have been denied by Medicare or have been adjusted to zero. This includes claims for which you are awaiting an appeal decision and those that were denied because they were filed too late. Modifier 25 may not be used on these items, even if you believe the claim should have been paid.
- Fewer than 20 percent of modifier 25 claims are correct, according to a recent study by the Office of Inspector General (OIG). The OIG believes that overuse of modifier 25 has increased significantly since 2009 when it first began tracking this issue as part of its ongoing efforts to improve Medicare payment accuracy and efficiency through targeted audits, reviews, investigations, and outreach programs aimed at eliminating improper payments from all government healthcare programs such as Medicare Advantage plans or Medicaid managed care organizations (MCOs).
Modifier 25 Should Not Be Used On Claims That Have Been Denied by Medicare Or Have Been Adjusted To Zero.
Modifier 25 should not be used on claims that have been denied by Medicare or adjusted to zero. If you are unsure if modifier 25 is appropriate, ask the payer.
Fewer Than 20 Percent Of Modifier 25 Claims Are Correct.
Modifier 25 is a modifier used to indicate that a procedure and an E/M service were performed during the same session or day. For example, if you had knee surgery with an additional evaluation and management (E/M) visit on the same day, modifier 25 would be added to your claim as follows:
- Procedure code: 17202 (knee replacement)
- Modifier 25: +17202 with E/M code 99213 (evaluation & management)
Overuse Of Modifier 25 Has Increased Significantly Since 2009.
Modifier 25 is used when a minor procedure (one with a 0- or 10-day global period) and a significant and separately identifiable evaluation and management (E/M) service are performed during the same session or day.
As it stands, modifier 25 is often overused. In fact, research shows that from 2009 to 2015 there has been an increase of 7% in claims submitted with this modifier. This is largely due to physicians’ confusion about its proper use.
Most Modifiers 25 Used Incorrectly Were Billed Inappropriately By Physicians, Hospital Outpatient Departments (HOPDs), Or Outpatient Surgery Centers (OSCs).
Most modifiers 25 used incorrectly were billed inappropriately by physicians, hospital outpatient departments (HOPDs), or outpatient surgery centers (OSCs).
- Most often, modifier 25 is not used at all. It should only be applied if two distinct services were performed during the same session or day. This usually occurs when a minor procedure like an office visit and an E/M service is performed during the same visit. In this case, you would use modifier 25 to indicate that there was no separate evaluation and management service provided for your minor procedure on that day.
The Use Of Modifier 25 Is A Problem, But It Can Be Corrected If Providers Are Aware Of The Rules Around It.
The use of modifier 25 is a problem, but it can be corrected if providers are aware of the rules around it. Modifier 25 should not be used on claims that have been denied by Medicare or have been adjusted to zero. Fewer than 20% of modifier 25 claims are correct, and overuse has increased significantly since 2009.
Conclusion
The use of modifier 25 is a problem, but it can be corrected if providers are aware of the rules around it. The OIG has identified the following trends in modifier 25 errors:
Fewer than 20 percent of modifier 25 claims are correct. Overuse of modifier 25 has increased significantly since 2009. Most modifiers 25 used incorrectly were billed inappropriately by physicians, hospital outpatient departments (HOPDs), or outpatient surgery centers (OSCs).
