UCR 101: Modifier 25 - deep dive

June 24, 2022

Mark and Scott welcome Dr. John Lin to the podcast to discuss in detail Modifier -25.

Skyline Urology to Pay 1.85M to Settle False Claims Act Allegations of Medicare Overbilling 

https://www.justice.gov/opa/pr/skyline-urology-pay-185-million-settle-false-claims-act-allegations-medicare-overbilling 

Also Corporate Integrity Agreement 

OIG Audit Modifier 25

https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

NCCI Policy Manual: https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare 

Chapter 7: GU System

The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. 

Cigna:  

https://www.cmadocs.org/newsroom/news/view/ArticleId/49780/Cigna-to-require-medical-records-for-all-modifier-25-claims
Cigna’s Modifier Policies: https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalModifiersPolicies.html

Cigna’s Modifier 25 Policies:
https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/Notifications/Modifier_25_Significant_Separately_Identifiable_Evaluation_and_Management.pdf 

Horizon BCBS: Beginning on August 1, 2022

https://www.horizonblue.com/providers/news/news-legal-notices/claim-reimbursement-update-e-m-codes-appended-modifier-25 

BCBS of Massachusetts: Effective July 18, 2022, 

https://provider.bluecrossma.com/ProviderHome/portal/home/news/news/claims-coding-payment/all%20networks/!ut/p/z0/rZBNb8IwDIb_Sjj0OMUU6ODYsbVl0E1oApVcJtMGyEiTkkZl_PulaEP70G4c4_eJ_diU0YwyhY3YohVaoXTvFQteE38y7k6H8BwHywjms_5o6N8uAOYBfaTMAcswSO6ixIdhGkUwefLjcBHFPRj12w7i7XBgIWW5Vpa_W5pVRjei4IZU2liU5BwoS6RYGzQnDy5A7soGpavs0JSYu0wbFwi1JSUvRH4WrT0oUUhSc9OInJMv-NPuog8T_x7mD93kpRdNexAH17KrLaoCpVbcAzT5TjS8IIof63aAb9JxuqWsQru7EWqjafaT-WX598j_NJHS_bdHbfb1tRZpfTzIJYqydnzR3rnCU-lyt9n3gdWerQeymW1SO1iFnc4H0ChcIg!!/