OIG Increases Scrutiny of "Modifier 25"

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Medicare payment rules normally do not permit additional payments to physicians for evaluation and management (E/M) services performed on the same day as a therapeutic procedure. However, if the E/M services are "significant, separately identifiable, and above and beyond the usual preoperative and postoperative care" normally associated with the procedure, a separate claim using "Modifier 25" may be submitted to receive an additional payment.

Some providers overuse Modifier 25, however. In two recent prosecutions, the OIG and federal prosecutors have settled with physicians who allegedly misused Modifier 25 to receive payments for services that did not meet those requirements. In the most recent case last week, a major Georgia oncology practice agreed to pay more than $4 million to settle claims that it overbilled Medicare for the use of Modifier 25. The $4.1 million civil settlement between Georgia Cancer Specialists I, PC and the U.S. Department of Justice settled claims that the Atlanta practice violated the False Claims Actby misusing Modifier 25. Although the Georgia practice did not admit any wrongdoing, it settled the claims "in lieu of an expensive and protracted legal process."

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