Recent Settlement Highlights Challenges in Modifier 25 Usage

In the latest Deeper Than the Headlines feature, we unpack a recent $427,000 settlement involving a Connecticut-based physiatrist and her practice that underscores a persistent risk area for providers: improper use of Modifier 25. 

Between April 2017 and August 2023, the practice allegedly submitted claims to Medicare that included Modifier 25 to justify billing for significant, separately identifiable evaluation and management (E&M) services in conjunction with pain injections. However, federal investigators concluded that many of those E&M services were not separately identifiable, making the additional charges improper. Notably, the physiatrist and her practice continued the billing pattern for nearly four years after being explicitly notified of the issue in 2019. 

This case is a cautionary tale for all healthcare organizations. Modifier 25 remains one of the most misunderstood and misused billing tools. While it’s a legitimate coding mechanism when appropriately applied, it has become a common trigger for audits and enforcement due to its potential for overuse. 

If you’re looking for additional resources on Modifier 25, check out our on-demand webinar, as well as the answers to additional questions from the webinar.