Audit & The Modifier 25 for Pain Physicians
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3 Ways Pain Physicians Can Reduce 25 Modifier Audit Risk


Avoid Being an Outlier on Medicare and
Private Payer Predictive Models

Medicare and private payers are identifying physicians who use higher numbers of E/M codes with a 25 modifier than their peers. Once identified, those physicians may be targeted for an audit. Here are three ways to make sure you don't stand out from the crowd.

1. Don't automatically bill an E/M code every time you perform an injection in the office. Pain physicians who do so are almost certain to bill a higher volume of E/M codes with a 25 modifier than those who don't, inviting the possibility of showing up on a payer’s high usage pattern report.

2. Understand that every injection includes pre-service evaluation time as part of the payment. Think of it as a mini-E/M. Performing pre-service work is inherent in your payment, so it can't be billed for separately. Payers include patient evaluation time in their reimbursement. Billing an E/M with an injection when your evaluation (and documentation) is focused on the presenting problem and the decision to perform an injection, may not meet a payers expectation as a "separate and significant E/M." Don't do it.

3. If you do perform an E/M service that is above and beyond the typical pre-service evaluation time, make sure there is medical necessity to do so. It's a no-no to extend the time of the visit or the level of the code unless there is a clinical rationale for doing so.
Learn More About Audits and the -25 Modifier for Pain Physicians

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