Nicoletti Notes June 2026
Published on June 11th, 2026
The OIG reviewed 100 claims with an E/M and minor procedure performed on the same calendar day and of the 100, only one (1) was assessed as not meeting the criteria for reporting the E/M with the minor procedure.
Are we coders and auditors using a higher, tougher standard than the OIG?
The OIG selected 100 Dermatology claims reported with both an E/M service and a minor procedure to assess if the use of modifier 25 was accurate. Of the 100, the OIG didn’t receive documentation for 5 services. Three E/M services were reported at a higher level than billed. One E/M service didn’t have the key components to support the E/M. And for one service, the OIG reviewer did not see that the E/M was significant and separate from the minor procedure.
Out of 95 reviewed encounters, one service should have been billed with only a minor procedure and didn’t qualify for an E/M with modifier 25.
- These were services performed in 2019-2020, so used the old 1995/1997 Documentation Guidelines
- The OIG report published in 2025 never mentioned the CPT® Assistant document published in March 2023 about using modifier 25
- The report notes that Dermatology has the highest frequency of use of modifier 25, reporting it 61.5% of the time. Other high frequency use specialties: Otolaryngology 49.8%, Podiatry 42%, Urology 29.2% and Orthopedic Surgery 26.3%.
- The title of the report is “Dermatology Providers Generally Met the Requirements for Evaluation and Management Services Performed on Same Day as Minor Surgical Procedures.” Generally Met the Requirements
When was the last time you did a modifier 25 audit report and found a 1% error rate? So, I am leaving you with this question, again:
Are we coders and auditors using a higher, tougher standard than the OIG?
References
Link to CPT® Assistant article on modifier 25: https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
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