#210 1 in 5 Modifier 25 Claims Might Not Survive an Audit

Resources 

• RECOVER Diagnostic: https://eligibility.natrevmd.com/recover-quiz-lp 
• natrevmd.com 
• Payment Posting Audit Checklist: https://eligibility.natrevmd.com/payment-posting-checklist 

Show notes 

A provider sees a patient for a scheduled procedure. A separate problem comes up mid-visit, gets evaluated, and the practice bills both services with Modifier 25 attached. The claim pays, and everyone moves on, until that same claim gets swept into a targeted payer audit because the documentation never actually supported a separate, significant E/M service. 

The three failure patterns 

Routine pre-procedure work billed as a separate visit:  

Baseline assessment before a procedure, confirming the patient is appropriate, reviewing labs, checking vitals, is part of the procedure. It is not a separate E/M, and Modifier 25 does not apply just because something happened before the procedure. 

Cloned or thin documentation:  

An assessment and plan identical to the note from two visits ago, or a problem mentioned in one line with no distinct plan, will not survive a payer review. The documentation has to show medical decision-making distinct from, and above and beyond, the procedure. 

Modifier 25 used to override a denial:  

A claim gets bundled and denied, someone appends Modifier 25 and resubmits, and it pays. If the documentation never supported a separate E/M, that resubmission was not a correction. It was a workaround, and it is exactly the pattern payer audits look for.

The global period trap 

Global periods run 10 days for minor procedures and 90 days for major surgeries. During that window, routine E/M care for the same procedure is bundled and not separately billable, even with Modifier 25 attached. A genuinely unrelated new problem may have a path to separate billing, but it needs documentation of the unrelatedness and compliance with payer-specific global period rules. Procedural specialties, surgical groups, orthopedics, gastroenterology, dermatology, OB/GYN, carry the most risk here. 

The five-question audit test 

1.  Was a significant E/M service actually performed, beyond the usual work of the procedure? 

2.  Is the separate problem, assessment, and management clearly visible in the documentation? 

3.  Would the E/M have been separately reportable if the procedure had not occurred that day? 

4.  Do current NCCI, global-period, and payer-specific rules allow Modifier 25 here? 

5.  Could the practice defend this claim on the medical record alone, not just the modifier? 

Three actions this week 

• Pull 20 to 30 Modifier 25 claims from the last 90 days across your most frequent providers and run each one through the five-question test. 
• Where claims fail, start with provider education, one conversation with examples from their own documentation, not a policy memo. 
• If more than 20 percent of the sample fails, add a pre-release review for high-frequency or high-risk providers for 60 to 90 days while the pattern corrects. 

Episode breakdown 

• The setup: what Modifier 25 is actually supposed to communicate 
• The three failure patterns 
• Three cases: yes, no, or verify 
• The global period trap 
• The five-question audit test 
• Running your own Modifier 25 practice audit 

Transcript

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SPEAKER_00 0:04

All right, so we've all been there. You see a patient for, say, a preventative or wellness check. And while they're there, they raise a separate problem that then you evaluate and manage. So you bill both services with the modifier attached to the ENM. So the claim gets paid, but then six months later, it's flagged as a payer audit, it's requesting documentation and potentially even a recoupment. So today we're going to talk all about Modifier 25 and how to protect yourself. Welcome to NatrevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. We all know that CMS is evaluating, cutting certain services when it comes to utilizing a modifier 25 by 50%. It is not a final rule yet, so please go check out and reach out to your representatives to make sure that you are giving feedback related to this potential CMS cut. So we are going to talk about modifier 25 and what it's actually supposed to communicate, and then how to foolproof your documentation to make sure that you are putting in the note what actually is needed to make sure that when a documentation is requested, you actually do get paid for this. So important to note that modifier 25 is a way for you to document what is going on with a patient that where you have two separate services that are significantly and separately identifiable from the, you know, one of the services compared to the other. So it's basically telling the payer on the same date of service, a procedure or other service is significant, right? So it's significant enough to deserve a visit or an evaluation and management. And it's separately identifiable to the other service that was performed that day. So it does not actually create the separate service. So that's important for you to understand. But the documentation has to show that the separate service actually happened. And paying a claim with a modifier 25 is not the same as that claim being compliant. So payers often pay first and then may audit later. And so it's really important for you to make sure that you have in your documentation proof that these two services, again, were separate and significantly identifiable. So where the misuse starts is that you may have two line items on a claim, maybe one's an e one's a procedure, and the practice ones both paid, but and someone amends with a modifier 25 and then the claim pays. The problem is the E and M documentation may describe work that was routine to the procedure and not separately and significantly identifiable. So you have to make sure that if someone is adding modifier 25, maybe that's you, maybe that's your billing team, that the documentation actually supports that modifier 25. So very important for you to ensure just because it was paid does not necessarily mean it was compliant. And this distinction matters, especially if you do have a targeted audit or a flag that says that they want to review that documentation. So nothing more painful than getting paid for that and then months later having a recoupment because it was not documented within the claim, or it was a situation where the modifier 25 was added in order to get the additional CPT code paid, but that modifier 25 was not justified. So we're going to talk about three failure patterns that we see in our 30 plus practices. Again, we are a full service revenue cycle management company. We support over 30 practices today, bringing in close to $10 million a month for our practices. We've got a great, amazing team. And these are things that we see as failure points that we are catching and trying to make sure are handled appropriately either before the claim is submitted or alongside documentation when it is requested. So failure number one is routine pre-procedure work build as a separate visit. So as we all know, every procedure involves some baseline assessment before it's performed. And that baseline assessment may mean confirming the patient is appropriate for the procedure, reviewing recent labs, checking vitals, et cetera. And that could all be part of the procedure. And so that's not a separate and significantly identifiable ENM service. So you have to make sure that you can't bill the EM and the procedure just based on those points alone. So the question is not, did the provider do something before the procedure? It's did the physician or provider do something that would have been billable as a separate ENM service if the procedure had not happened? So if the answer to that is no, then the modifier 25 is not going to be appropriate for that. Now, failure number two is thin documentation. I cannot tell you guys how often this is really the case. So the provider documents a problem list, the note looks like a full visit, but then the assessment and plan are identical to the note from several weeks ago. Or the note is brief, it's maybe got one or two lines talking about the EN proportion, the evaluation and plan portion and management of the patient. And so there's no distinct assessment or plan specific to the problem. So an example to this could be you do a wellness visit and you mention a whole bunch of problems in that wellness visit, but then you don't have a documentation around assessment or management of those problems or any of those problems, but you also throw in alongside the wellness visit. So in that case, you've talked about all of these problems, but you've not actually shown or documented that you did an level assessment and plan in order to match the separate and significantly identifiable EM and modifier 25. So we see that very, very often. Basically, the documentation is just very, very thin, right? You do this whole beautiful documentation for a wellness visit, but when it comes to the EM side of things or addressing a problem, the documentation does not stand on its own as a separately and significantly identifiable service. And that will not survive a payer review. So the documentation has to have medical decision making that is distinct from the wellness visit, for example, to go above and beyond the work of that wellness visit. Now, failure number three that we see is modifier 25 used to override a denial. So claim comes back denied because the payer bundled in the ENM with a procedure. And someone on the billing team just decides to throw on a modifier 25 and resubmit it. Claim pays. But then if the documentation didn't support a separate ENM and the resubmission was not justified, right? So they added the 25 to get both CBTs paid, but in reality, the modifier 25 was not supported by the note, then that pattern is going to be something that is caught in a payer audit. And you're basically having a billing team add something where it really wasn't justified. So really need to make sure that if a modifier 25 is added and the both CPTs do get paid, that the documentation does really support it. Or don't have your team add the modifier 25 unless the note is reviewed. Now, the struggle around this is that sometimes the individuals who are throwing those modifiers on are not certified billers or certified coders. So they're billers who are trying to get things paid. And if they're not a certified coder, then they're not looking at the documentation to ensure that it is truly an appropriate modifier to use. So three very different failure points that we see that is important for you to understand if you are overseeing a practice. All right, so now let's talk about a few cases. So case number one, say you've got primary care, you're doing an injection visit. So a patient is scheduled for a B12 injection during the visit, they raise a new problem. Say they've got a skin rash that appeared in the last week. And so the physician evaluates the rash, reviews the history, and documents a distinct assessment and plan, including a prescription for that rash. So the question is, is that separate reportable? So potentially, yes, right. So the rash evaluation is going to be distinct from the injection. The documentation does need to clearly support a separate problem on its own assessment in management and needs to have all of that documentation within the note. So whether that's, you know, the prescription used to manage the rash, et cetera, and the work would have been billable if the injection had not occurred that day. So then the modifier 25 would be appropriate to add on. Now, obviously, there's going to be some payers that may balk at this, but in general, that is the coding requirements. Now, so case number two. So you've got an allergy patient there for an immunotherapy visit. So patient arrives scheduled for allergy immunotherapy, clinician reviews the patient before the injection, confirms no recent reactions, checks current medications, administers the shot, no new problems are raised or evaluated. Now, is this an example of where you would have a separate ENM supporter? No, of course not. Right? So the pre-injection review is routine, work, it's associated with the immunotherapy service. It's not separately and significantly identifiable. So you would not want to identify or add an with a modifier 25 to this date of service, at least not based on that story. Now let's do another one, case number three, where we've got urgent care and a minor procedure. So a patient presents, say, with a laceration that requires repair. And while obtaining the history provider identifies and evaluates an unrelated problem, say elevated blood pressure and associated symptoms. So it requires its own assessment and management. Both services are documented separately. And the question is, is this supportable? So yes, but you've got to make sure that you're documenting this appropriately and that of course it's per payer policy. So the key is whether the for the blood pressure issue is generally above and beyond the laceration. Yes, if you're doing an assessment, you're getting a history and you're actually managing that blood pressure issue. And so if that is the case and you've documented that, then you can add the EM alongside the laceration repair with a modifier 25. So the pattern across all of these cases is of did you do two things? Did you document two separate reportable services as if each could stand alone on its own? And is that all present in the documentation that you would submit? Say a payer were to ask for that documentation. So really, really important to make sure that if you are applying that modifier 25 to any service, that you do have two separate things that are going on. They are significant and separately identifiable, and the documentation supports a full EM as if it were standing on its own. Now, important for you to make sure that when working with your billing team, that when they are adding that modifier 25, that either they are working with the practice to make sure that that is truly separately and significantly identifiable service. It's documented and ready for that modifier 25 to be appended. Again, the worst case scenario is that you add it and then you get paid, but then it did the documentation didn't truly justify the adding that modifier 25 for a separate service. Really important for you to understand these things, work with your billing team, and make sure that you are thinking about this as we go into quarter four. So last but not least, we do have a diagnostic survey down in the bottom. If you're sitting there going, gosh, I'm going into quarter four, I don't know where my practice metrics are, I don't know how to really understand if I'm doing a good job or if I need help, head on over to the show links down in the or the show notes down below and check it out. And you can fill out a couple of questions, understand where you're at. And if you need to be working through some things, then it guides you to some simple things that you can put into your practice to help improve revenue. As always, if you are looking for a new billing company, we would love to meet with you. And we do a free revenue audit, metric audit for those practices, typically with greater than three to four doctors or providers per practice. So head on over to notrevmd.com, top right hand corner, and you can check out a uh the revenue audit uh and book a time. All right, I hope you guys have a great rest here.