Wiki Inappropriate Modifier -25 use

[ebonih9@gmail.com]

Hello, I work as an auditor for compliance and we have been seeing an up-kick in providers appending modifier 25 to ALL claims. Most of the services included on the claim do not require this modifier and some claims only have 1 service line so the modifier is not needed. I researched CMS to see if we should deny claims for inproper use of modifier even if it does not effect payment and I didn't find a definitive answer. I posed this question in the coding forum and I received the response to let it go and to not deny claims for modifier -25, HOWEVER in audit it is different. The purpose of auditing is to ensure that proper coding guidelines and regulations are met! We are suppose to look for coding accuracy and compliance.

We know that the provider is appending this modifier to all E/M services to bypass and edit if one should effect the claim so I feel like it is being dishonest and abusive. I would love to get feedback from other auditors on this matter please. Thank you

 

[CBLENNIE]

I work as a compliance specialist for commercial plans and the carrier I work for does not deny for unnecessary use of modifier 25. However, the providers who are doing it are definitely being watched by our SIU & Payment Integrity teams.

 

[ebonih9@gmail.com]

I work as a compliance specialist for commercial plans and the carrier I work for does not deny for unnecessary use of modifier 25. However, the providers who are doing it are definitely being watched by our SIU & Payment Integrity teams.

Oh okay, We sit under legal with the SIU and audit for them as well. So does your SIU intervene?

 

[CBLENNIE]

In my role I am not privy to the actions taken or not taken by our SIU department. Also, we don't sit under Legal, we are under the Chief Audit Executive.