Claims Denied

Major insurers push back on claims involving modifier 25 and 59

DOs are advised to take a look at their clinical documentation practices as a growing number of large insurers deny claims.

Physicians are advised to review their documentation practices in light of reports from DOs experiencing payment denials related to clinical validation edits made by an increasing number of large payers.

DOs began reaching out to AOA for assistance earlier this year when Health Care Services Corporation (HCSC), which operates Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, made changes to its automated payment policy rules regarding claims using modifiers 25 and 59.

That edit initiated significantly increased scrutiny by the HCSC insurers of documentation for claims and resulted in payment denials for part of the services provided, according to AOA staff working on behalf of affected DOs.

Multiple specialties affected

The 15 DOs reporting the most problems have practices that focus on osteopathic manipulative treatment, but the HCSC edits do not appear to be specifically targeting OMT. Instead, this broadening scrutiny of claims involving modifier codes is hitting a multitude of specialties, including dermatology and pain management.

AOA staff is concerned that other large payers will adopt similar edits regarding the use of modifier 25, which means that physicians will have to spend more time on clinical documentation if they want to win appeals. Auditors need to see more detailed documentation of the evaluation and management (E/M) services as well as the procedure for a physician to successfully appeal.

“The E/M documentation guidelines for physicians are 20 years old, but the documentation standards payers are enforcing are vastly different from what they were even 10 years ago,” said Mat Kremke, vice president of the American Osteopathic Information Association, which provides physician services to AOA members. “These changes reflect a shift toward value-based care.”

Clinical documentation improvement will streamline reimbursement in most cases, Kremke said.

Tips to improve documentation:

  • Write legibly or simply do not handwrite any part of the patient’s medical record. Illegibility often results in claim denial.
  • Avoid cutting and pasting notes in the EHR. While the process saves documentation time, it also puts up a red flag to auditors.
  • Make sure the documentation supports a separate E/M for the visit. Insufficient notes may result in this part of the claim being denied or reduced.
  • Avoid upcoding. Payers are aggressively reviewing claims for the appropriateness of the E/M level.

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‘Looking for the patient’s story’

“Coders and auditors view medical records very differently, and it’s the auditor’s opinion that determines the outcome of the appeal. An auditor is looking for the patient’s story and the physician’s thought process to understand treatment decisions as they pertain to each visit,” said Boyd Buser, DO, AOA past president. Dr. Buser represented AOA physicians in a recent meeting with HCSC to discuss the impact of the rule edits.

“Red flags occur when the documentation repeats the same case notes, either verbatim or nearly identically, and doesn’t reflect any changes and improvements over the course of treatment,” Dr. Buser explained.

The AOA has joined with a medical association staff coalition to jointly address these issues. Members of the coalition include AOA payment policy staff as well as representatives from dermatology, pediatrics, neurology, urology, pain management, ophthalmology, otolaryngology, rheumatology and obstetrics and gynecology associations.


  1. Ronald J.Peplow D.O.

    The contract stipulates peer review. How many of the
    paid reviewers have a certificate in OMM? Being reviewed
    by a collegue,who has no or minimal knowledge of OMM
    is akin to giving a clock to a horse. If the modifier is denied
    ask who reviewed the chart because review by a collegue
    is breech of contract. The chart should be reviewed by a

  2. Shawn Kerger, DO, FAOASM

    I had one experience with this in Virginia – had a sit-down meeting with the insurance company rep and a phone in physician reviewer on a case of a patient who was coming in for follow-up TMJ treatment with OMT but had a new-onset lumbar disc herniation that I diagnosed and managed in the same visit. It was denied initially and when I presented the case, the initial physician reviewer stated that all my orthopedic exams (Lesague, Braggard’s, Kemp’s, etc.) were osteopathic exams and covered under the OMT portion of the billing. I then informed those in the meeting that these were orthopedic texts – and that they could reference any orthopedic or neurologic spinal exam text and find these there and NOT in an osteopathic text under osteopathic findings.

    The physician reviewer on the phone was quite quiet initially till I asked what he thought. His comment was that he was glad that he was not the reviewer on the case – and that the physician who had been was a retired OB/GYN allopathic physician.

    The decision was overturned and I never had a problem thereafter with that insurance company. I cannot agree further that such reviews should be made by an osteopathic physician in the specialty field being reviewed.

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