UCR 101: Modifier 25 - deep dive

June 24, 2022

Mark and Scott welcome Dr. John Lin to the podcast to discuss in detail Modifier -25.

Skyline Urology to Pay 1.85M to Settle False Claims Act Allegations of Medicare Overbilling 


Also Corporate Integrity Agreement 

OIG Audit Modifier 25



NCCI Policy Manual: https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare 

Chapter 7: GU System

The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. 


Cigna’s Modifier Policies: https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalModifiersPolicies.html

Cigna’s Modifier 25 Policies:


Horizon BCBS: Beginning on August 1, 2022, we will consider E&M services appended with Modifier 25 at 50 percent of our appropriate Horizon allowance (or at the provider’s submitted charges if less) if one or more procedure codes that have a global surgical period of 0, 10 or 90 days are included on the same claim or on another claim for that same date of service. 



BCBS of Massachusetts: Effective July 18, 2022, we will enhance our claims editing system to improve its overall accuracy regarding modifier usage. Currently, some modifiers including, but not limited to, 25, 59 (X-EPSU subset), 79, and 24 are inappropriately overriding unbundling edits in certain situations. Based on an extensive assessment of modifier use, the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) have advised the use of pre-payment modifier review based on claim details and patient claim history. 

Consistent with the recommendations of the OIG and CMS, Blue Cross will implement enhanced editing based on national guidelines for modifier usage. As part of this process, registered nurses with coding certifications will look at claim data in conjunction with patient claim history to confirm appropriate modifier use. 


Dr. Lin is the administrator of The Thriving Urology Practice Facebook group.

The Thriving Urology Practice Facebook Group link to join:


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PRS Network Presentation Team

  • Dr. John Lin
  • Mark Painter
  • Scott Painter

From the perspective of a practicing Urologist and experts In Urology Coding.

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