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Cal Stein, a partner with Troutman Pepper, was quoted in the October 2, 2023 Part B News article, “$850K for Misusing Modifier 25? Tighten Up on Policy and Patterns.”
Callan G. Stein, a partner with the Troutman Pepper firm in Boston, thinks this is related to the “unbundling” effect of modifier 25 abuse.
“The modifier has the effect, intentionally or not, of unbundling services and billing them separately when they should be billed together,” Stein says. “The prosecutor alleged that by using the modifier the provider represented that it had performed E/M that was not part of the procedure, i.e., a separate E/M. If the only E/M performed was actually the E/M associated with the procedure, then the modifier should not have been used and the E/M should have been bundled with the procedure codes.”
And it’s not as if a false 25 claims is insignificant. Stein points out that an OIG report from November 2005 “specifically addressed the use of this modifier. It found 35% of the claims using that modifier did not meet program requirements — which meant CMS believed it had paid out more than half a billion dollars — 2005 dollars! — that it shouldn’t have. So it’s not shocking to see that we’re still seeing these types of cases years later.”
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Train coders and billers. Stein believes “the number-one thing providers can do is to train the people who are submitting the bills to know all of those nuances and to identify and recognize them before the government does.”
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