Medicare Compliance & Reimbursement

The bell curve won't shield you from modifier 25 scrutiny.

Myth: If you bill mostly 99213s and keep your evaluation & management (E/M) billing within the "bell curve," you'll avoid the heat for using the 25 modifier (Significant, separately identifiable evaluation & management by the same physician on the same day of the procedure).

Truth: The HHS Office of Inspector General (OIG) and other federal watchdogs are sniffing claims with the 25 modifier, regardless of coding level, says Devona Slater with Auditing for Compliance and Education in Leawood, KS. Some providers believe that they can fly under the radar by sticking to mid-level E/M codes most of the time, but this practice won't protect you.

"If you're using the modifier 25 and you're billing routinely a lot of E/M services with modifier 25, you're bound to be red-flagged at some point regardless of what level of service," says Maggie Mac, consulting manager with Pershing Yoakley & Associates in Clearwater, FL.

The 25 modifier is a hot button at the moment, Mac adds. The OIG issued a tough report on the 25 modifier in 2005, and then the Centers for Medicare & Medicaid Services (CMS) followed up last May with Transmittal 954 (CR 5025).

In that transmittal, CMS emphasized that you can only use the 25 modifier when the E/M is different from the usual pre- and post-operative work for a surgical procedure. Your doctor must document why the separate E/M was necessary and exactly what he or she did, CMS stressed.

You can't use the 25 modifier unless the E/M is "a separate and distinct service," Slater stresses. Rather than trying to get most of your darts in the middle of the board, you should try to code correctly, she insists. "You have to understand Medicare's table of risk and the
decision-making process."

Watch out: According to the Social Security Act, undercoding is as illegal as overcoding, says Deborah Churchill with Churchill Consulting in Killingworth, CT.