The Office of the Inspector General maintains Modifier 25 as a target of its work plan each year. One of the types of reviews under Modifier 25 audits is chemotherapy infusion on the same day as an evaluation and management (E/M) service. Recovery audit contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and commercial payers often perform these audits as well. The U.S. Department of Justice has also reached settlements with providers on this topic. Many providers have fought and lost the battle as their E/M is denied due to the lack of supporting documentation above and beyond the chemotherapy infusion.
PYA Principal Valerie Rock joined Myla Reizen, a partner with K&L Gates, to discuss an administrative law judge’s recent appeal decision in which a practice was successful in overcoming denials—a rare occurrence.
In this one-hour webinar, Valerie and Myla covered the background and tactics of this successful appeal strategy, including:
- The history of the bundling of an E/M in the chemotherapy infusion.
- Understanding what the common clinical reasoning is for performing an E/M during the period of treatment cycles.
- Advancing your strategies as we take a deep dive into examples of a successful appeal and tactics applied.
The webinar took place on December 16, 2021.
Resources: Slides
This webinar was part of PYA’s twice-monthly “Healthcare Regulatory Roundup” series in which experts from across the firm provide practical insights on the latest regulatory developments.
If you would like additional guidance related to billing with Modifier 25 or E/M, or for assistance with any matter related to compliance, valuation, or strategy and integration, contact a PYA executive below at (800) 270-9629.
