PYA Principal Valerie Rock is quoted in the Report on Medicare Compliance April edition in an article that provides insight into a recent civil monetary penalty (CMP) settlement. In “Hospitals Pay $12.7M in CMP Settlement Over Pain Management Procedures, E/M Services,” Valerie noted many providers face challenges with procedures billed at the same time as evaluation and management (E/M) services. This is because Medicare only pays providers for E/M services performed on the same day as a procedure when those services are significant and separately identifiable. Providers then append with Modifier 25, the misuse of which has become a top billing compliance risk area.
Article Excerpt
To get their arms around this, Rock recommends providers run data on their use of injections and infusions with and without the reporting of an E/M or the percentage use of Modifier 25 on E/M codes. They can compare the numbers to comparable providers in the state with respect to modifier use on Medicare comparative billing reports. Local coverage determinations also are available for use of facet joint injections. “Make sure your review is apples to apples and get a sense of whether you’re off track or not.”
Read the full article here.
During a December 2021 webinar, Rock discussed Modifier 25 in further detail with Myla Reizen, a partner with K&L Gates. The webinar can be found here.
If you would like additional guidance related to billing E/M services and the use of Modifier 25, or for assistance with any matter related to compliance, valuation, or strategy and integration, contact a PYA executive below at (800) 270-9629.
