OIG Alert: Review of Same Day E/M and Surgery Claims Billed Without Modifier 25

Last week, HHS Office of Inspector General (OIG) added a new Work Plan project which will examine evaluation and management (E/M) services billed on the same day as minor surgical procedures without modifier 25. The OIG anticipates that the review will be completed in 2028. The review was prompted by an analysis of Medicare Part B claims from 2023-2025 that identified same-day E/M services that were processed and paid without modifier 25. The agency will assess whether Medicare Administrative Contractors (MACs) processed and paid those claims in accordance with Medicare requirements.

While this review requires no immediate action or concern for our members, it does underscore the importance of ensuring that the use of modifier 25 is appropriate, clearly supported by documentation, and consistent with Medicare billing rules. Members can access additional guidance and educational resources on APMA's 25 Modifier Toolkit page.

Contact the APMA Advocacy Department with any questions at [email protected].