03/03/2020

COA Comments on Modifier 25 Audits Process

Practices Should Not Have Payment for Entire Claims Held 

In recent months, it has come to COA's attention that there is widespread implementation of Targeted Probe and Educate (TPE) audits that are investigating the use of modifier 25 codes for evaluation and management (E&M) visits on the same day as drug administration, particularly Part B chemotherapy and immunotherapy drugs. 

While COA strongly supports appropriate checks and balances in providing cancer care to seniors and others covered under Medicare, these audits are having a very serious negative impact on community oncology practices because the entire claim is being held up for payment while a single line item is being audited. These concerns were shared with CMS Administrator Seema Verma in a letter last week.

The result of this is that a practice’s cash flow may be severely impacted for up to 75 days as the practice continues to provide cancer care to their patients. Having drug claims for purchased and administered Medicare Part B drugs outstanding is an incredible financial hardship for small practices who must still make payment for the drugs given to patients. Not only can this affect a practice’s financial credit, but also their long-term survival as a source of quality, high-value, and accessible cancer care for the communities they serve.

• Read COA's full letter to CMS on the TPE Modifier 25 Audits.