OIG Increases Scrutiny of "Modifier 25"


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."

Please see full alert below for more information.

LOADING PDF: If there are any problems, click here to download the file.

Written by:

Published In:

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Jackson Walker | Attorney Advertising

Don't miss a thing! Build a custom news brief:

Read fresh new writing on compliance, cybersecurity, Dodd-Frank, whistleblowers, social media, hiring & firing, patent reform, the NLRB, Obamacare, the SEC…

…or whatever matters the most to you. Follow authors, firms, and topics on JD Supra.

Create your news brief now - it's free and easy »

All the intelligence you need, in one easy email:

Great! Your first step to building an email digest of JD Supra authors and topics. Log in with LinkedIn so we can start sending your digest...

Sign up for your custom alerts now, using LinkedIn ›

* With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name.