The Problems Associated with Modifier 25

FWA issues associated with modifier 25 are not new, Use of Modifier 25 guidance was published by the Office of the Inspector General (OIG) in 2005. (


The report concluded of the roughly $2 billion allowed for evaluation and management services reported with procedures, 35% were paid in error. Upon review, a significant portion of the claims were not supported by adequate documentation to justify medical necessity.


In the last 15 years, the problem of modifier 25 overutilization persists as demonstrated by a steady stream of associated fraud headlines, specialty society articles, and published carrier guidelines which necessitates new tools and strategies to identify when modifier 25 is improperly reported.


In order to combat and manage FWA associated with modifier 25, deploying a pre-pay detection platform like the Sharecare Payment Integrity Centaur will recognize and prevent erroneous payments from “going out the door”.


The Centaur uses artificial intelligence to develop statistical “standards of care” for providers and carriers which allows anomalous claims activity to be identified and to know whether there is a history of behavior with a given provider that aligns with what one would expect.   Another feature of the system is streamlining the request and delivery of documentation to validate AI suspicion and train the platform for the future encounters of that provider’s claims.

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