Excessive Use of Modifier 25
CareOregon and its affiliated entities value compliance with laws, rules, ethical standards, and contractual obligations. The Payment Integrity team at CareOregon has identified some providers/clinics as outliers in billing evaluation and management services
with modifier 25.
Please be aware that CareOregon is assessing the use of modifier 25. All providers/clinics that bill with modifier 25 on more than 75% of their evaluation and management services will be subject to 100% prepay audits.
If subjected to a prepay audit, all claims that include services billed with modifier 25 will require the submission of clinical documentation to support a significant and separate evaluation and management service, in addition to other services rendered
on the same day. The prepay audit hold on claims will remain in effect until CareOregon determines that there is a high level of accuracy in claims submissions.
For reference, please see the coding guide on the appropriate use of modifier 25.
If you have additional concerns or updates, please contact the CareOregon Payment Integrity team at
Fax: 503-416-1381 / Attn: Payment Integrity
Attn: Payment Integrity Department
315 SW Fifth Avenue
Portland, OR 97204