tci Medicare Compliance & Reimbursement - 2013 Issue 4

Appeal Strategies: Appeal Modifier 25 Denials Effectively

Avoid missing out on deserved reimbursement with these four steps. If you feel that recent payer crackdowns on the overuse of modifiers, especially modifier 25, have affected you adversely, you’ll benefit from a refresher on how to appeal and successfully recoup your pay. 1. Check Documentation Meets Modifier 25 Criteria You should first verify that your physician’s chart note supports billing an E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of another service or procedure). Per CPT® guidelines, minor procedures have a small E/M service built...

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