Modifier-25 abuse — separate E/M billed alongside a procedure

What this looks like in practice

Modifier 25 ("significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure") was created to compensate doctors for genuinely separate work. The classic example: patient comes in for a knee injection but during the visit also reports new chest pain that the doctor evaluates. The chest-pain evaluation is separately billable.

The pattern OIG flags: routine pre-procedure work — explaining the procedure, getting consent, prepping the area — billed as a separate E/M with Modifier 25. Most specialties have audit findings showing inappropriate use ranging from 30% to 60% of claims with Modifier 25 attached. The patient's tool: the medical record either documents two distinct services or it doesn't.

How to spot it on a bill

• 01.Two CPT codes on the same date with the same provider: a procedure (e.g. 20610 joint injection) and an office visit (99213, 99214) with -25 modifier.
• 02.The chart documents the procedure but the 'separate' E/M just describes pre-procedure assessment, consent, or post-procedure recheck.
• 03.The visit reason (chief complaint) is the same as the procedure indication.

What to write — ready-to-paste language

Replace the bracketed fields with your specific details. Send by certified mail with return receipt, or via the hospital’s patient portal if it offers documented messaging. Keep a copy.

On the bill dated [date], provider [name] billed both CPT [procedure code] and CPT [E/M code]-25 (Modifier 25) for the same encounter. Per CMS Pub. 100-04 Ch. 12 §30.6.6.B, Modifier 25 requires that the E/M service be "significant" and "separately identifiable" from the procedure — meaning addressing a different problem or requiring work beyond what's bundled into the procedure fee. The medical record for this visit (which I have requested per HIPAA §164.524) should document two distinct services. Please review and, if the documentation does not support two separate services, recode and adjust.

This is a starting point, not legal advice. Your specific situation may warrant additional details. Our scan tool drafts this letter automatically with your bill’s specifics filled in.

CPT codes commonly involved

These codes often appear in bills affected by this pattern. Click through for the federal benchmark price on each.

• CPT 99213
• CPT 99214
• CPT 20610
• CPT 11102
• CPT 17000

Related scenarios

• Upcoded ER visit — when the level on the bill doesn't match the chart

  ER visits billed at a higher complexity level than the medical record supports are the most common billing-error pattern in the country. Federal coding rules let you dispute the level.

• Unbundled charges — when one procedure gets billed as several

  Federal coding rules (NCCI edits) explicitly prohibit billing certain combinations of CPT codes together. When you see them on your bill, the federal benchmark gives you grounds to dispute.

• Wrong place-of-service code — facility billing for a non-facility visit

  Place-of-service codes determine whether Medicare and most insurance pay the higher facility rate or the lower non-facility rate. A code mismatch can inflate a bill substantially.

• Observation vs. inpatient — billed under the wrong status

  Observation status looks like an inpatient stay to the patient (same room, same care) but bills under outpatient rules — which can mean much higher cost-share for Medicare beneficiaries and a denied SNF benefit.

Common questions