Compliance: Check your modifier 25 claims before OIG audit hits

Why This Topic Matters

The topic matters because same-day reporting of evaluation and management services with procedures is a common audit focus, and errors can affect claim payment, denial risk, and compliance exposure. The article highlights why internal review and payer-specific documentation checks are important for practices across specialties.

Article Sections

1. Defining minor procedures

   Introduces the general compliance issue of reporting evaluation and management services alongside procedures and explains the broad context for the audit focus. It also discusses the general concept of minor procedures and how post-service periods are relevant to this topic.

2. Correct use of modifier 25

   Covers the general requirements for reporting a separately identifiable service on the same day as a procedure and the documentation considerations involved. It also discusses the relationship between included procedure work and separately reported services.

3. Incorrect use of modifier 25

   Reviews common compliance concerns when same-day reporting is not supported and emphasizes the need to distinguish included work from separately reportable services. It also points readers toward authoritative sources used to evaluate procedure inclusions.

4. Prevention is key

   Discusses internal auditing and monitoring practices, including review timing and operational risks in claim handling. It also addresses why ongoing review of external guidance can help reduce compliance problems.

5. Tap into authoritative documents

   Summarizes the types of payer and policy documents that may be used to support claim review and compliance decisions. The section distinguishes between Medicare-related sources and commercial payer sources at a general level.

6. Reimbursement check

   Explains that payment review is part of the overall compliance process and notes that payer policies and contract terms can affect claim outcomes. It also touches on denial data, audits, and claim-processing monitoring.