Audits: RACs Are Now Checking Your Modifier 25, Injection Claims

Why This Topic Matters

RAC activity can lead to overpayment reviews and denials if claims are submitted with inaccurate service settings, incomplete supporting documentation, or billing patterns that do not align with Medicare payment rules. Knowing the audit focus areas helps practices assess risk and review their internal billing processes.

Article Sections

1. Consolidated Billing

   Discusses Medicare consolidated billing in the skilled nursing facility setting and the general distinction between facility-responsible services and separately reportable professional components.

2. Modifier 25 With Dialysis

   Covers RAC review activity involving evaluation and management reporting on the same day as dialysis services and the related documentation focus.

3. Inpatient vs. Outpatient

   Addresses audit attention to place of service reporting when services are furnished in a facility rather than an office or other non-hospital setting.

4. Pain Management Injections

   Summarizes RAC scrutiny of epidural injection claims, including diagnosis alignment and documentation themes associated with pain management procedures.

5. Bilateral Billing

   Describes audit issues related to bilateral service reporting patterns and billing structure for services with bilateral indicators.