OIG Work Plan Focuses on Same-Day E/M Services and Minor Procedures
Issue: The HHS Office of Inspector General (OIG) has added a Work Plan item reviewing Medicare payments for evaluation and management (E/M) services performed on the same date as minor surgical procedures when modifier 25 was not appended.
Why this matters: Medicare includes the E/M work associated with a minor procedure in the payment for that procedure. A separate E/M service may be payable only when the visit is significant and separately identifiable from the usual preoperative and postoperative work of the procedure. Modifier 25 indicates that the same-day E/M service meets this requirement.
OIG focus: OIG analysis of Medicare Part B paid claims from calendar years 2023 through 2025 identified E/M services performed on the same day as a minor surgical procedure that were processed and paid without modifier 25. OIG will review whether Medicare Administrative Contractors processed and paid these claims in accordance with Medicare requirements.
Coding reminder: Do not report a separate E/M service on the same date as a minor procedure unless the documentation supports a significant, separately identifiable service that goes beyond the usual work included in the procedure.
Append modifier 25 only when the E/M service is medically necessary, significant, and separately identifiable.
Ensure the medical record clearly supports the separate E/M service, including the assessment, decision-making, and plan unrelated to the minor procedure’s inherent work.
Review same-day E/M and minor procedure claims for proper modifier use before submission.
When modifier 25 is not supported, do not bill the E/M service separately.
Action for coding and billing teams: Include same-day E/M and minor procedure claims in routine audit activity, with special attention to claims paid without modifier 25 and claims where modifier 25 is appended without clear supporting documentation. If you have not had a Medical Coding Audit recently, it may be time to engage a consultant to review documentation supporting the E/M with a procedure on the same date of service.
