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In 2004, the Health & Human Services (HHS) Office of the Inspector General (OIG) reported that 35% of claims appended with modifier -25 did not meet the required threshold to be appropriate.
Based on comments from the Health and Human Services Department Office of Inspector General, (OIG 2012 Audit Work Plan) and past Medicare and Medicaid audits, it seems for now the low-hanging fruit is the 99214/99215, and modifier -25 outliers will be likely targeted.
Such preventive counseling can be reported in addition to a problem E/M service by adding the modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M code.
3 Remember to use modifier -25 with the proper documentation
The Office of Inspector General notes that you can bill for an office procedure performed on the same day as you evaluate the patient, if the procedure "is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure...." To do so, though, it is necessary to attach modifier -25 to the evaluation and management (E/M) code, and to provide evidence that you performed 2 separate services.
In 2002, Medicare approved some 29 million claims using modifier -25, then disallowed nearly 35% of them for failing to meet the documentation requirements.
And the insurers will no longer automatically downcode evaluation and management codes, and will separately identify and pay modifier -25, which allows physicians to bill for evaluation and management service on the same day as a procedure.
If, for example, uroflowmetry is performed as part of the intake examination for a patient with stress incontinence, modifier -25 enables one to bill for it as a separate E&M service, distinct from the history and physical or general physical exam for incontinence.
Self-audit your level 4 and 5 E & M codes and your modifier -25s to ensure you comply with all the necessary documentation.