Modifier 25 Fraud: The Visit Already Paid for in the Procedure

Modifier 25 fraud bills a government health care program for a separate visit when the work was already included in the procedure’s payment. The patient came in, the clinician provided care, and the practice submitted an extra evaluation and management claim. The question is what separate service earned that extra payment. If you see the procedure note, the coding instructions or the software that creates the claim, you may know why the billed visit and the actual encounter tell different stories.

What Modifier 25 Is Supposed to Show

Modifier 25 goes on the evaluation and management service, commonly called E/M, to identify significant, separately identifiable work beyond another service provided that day. The extra claim represents additional clinical work. A template, another diagnosis or a new-patient designation cannot supply that work by itself.

Medicare pays for a minor surgical procedure as a package that includes the usual work before, during and after it. The decision to perform that minor procedure belongs in its payment. The Medicare coding rules distinguish that from the decision for major surgery, which uses Modifier 57.

A separate diagnosis is neither necessary nor sufficient for the added E/M service. The chart needs to show the significant additional evaluation and management, even when both services concern the same diagnosis.

There is money behind the distinction. Medicare’s physician fee schedule values practitioner work, practice expenses and malpractice costs. The Robert Wood Johnson Foundation’s Physician Self-Referral and Physician-Owned Specialty Facilities, published in 2008, explains how fee-for-service payment made procedural services generally more profitable per unit of time than services involving thinking and talking with patients. A practice billing both a procedure and a visit claims payment for both kinds of work. In an added-visit scheme, the government pays again for work the procedure already covered.

When the Visit Is Already in the Procedure

An eye examination used to decide whether to give an intravitreal injection can be part of the injection’s payment. The Health and Human Services Office of Inspector General illustrated that boundary in its May 2025 eye-injection audit. One record showed a follow-up visit for wet age-related macular degeneration in the right eye and a decision to inject that eye. Medicare paid $91 for the injection and another $103 for the E/M service, which the auditors found unsupported. The added visit cost more than the procedure whose decision it duplicated.

The same report describes a supported additional service. While examining a patient who received an injection in the right eye, the provider identified signs of a separate condition in the left eye. The provider addressed that condition through education about its prognosis, home monitoring and risk factors. The record showed what the additional care consisted of.

That comparison matters inside a practice. A note that says both eyes were examined still leaves the question of what the clinician evaluated and managed beyond the injection. The audit described another provider who thought a comprehensive examination of both eyes justified the extra claim, but whose documentation showed only the work inherent in the injection.

The level of the added visit must also match the work, a distinction that matters when a practice inflates both the number of services and their complexity. The Centers for Medicare & Medicaid Services’ office-visit guidance bases the level on medical decision making or qualifying practitioner time, rather than the length of the history or examination.

What Are Some Examples of Fraud in Medical Practice?

The civil cases show extra visit claims arising from routine procedure work, unsupported visit levels and software that creates an E/M charge from a notation. The useful comparison is where the added claim enters the process: the clinician’s documentation, the billing instructions or the program that converts an encounter into a bill.

Skyline Urology and the Routine Visit Charge

Skyline Urology agreed to a $1,850,000 settlement announced in February 2019. The Justice Department alleged that the practice used Modifier 25 to bill Medicare separately for routine E/M services already included in same-day procedures, from January 2013 through December 2016. The additional payment depended on representing that significant, separate work had occurred.

A healthcare consultant brought the whistleblower case. Skyline also entered a three-year integrity agreement requiring billing monitoring. The case puts the routine extra visit charge in focus: a real procedure can sit beside an alleged false claim for additional care.

Toccoa Clinic and the Level of the Added Visit

Toccoa Clinic Medical Associates and two physicians agreed to a collective $1,900,000 settlement announced in April 2016. The Justice Department alleged that they billed E/M services on procedure days without significant, separately identifiable work, and also billed visit levels higher than the documentation supported.

That puts two questions into the same encounter. What supports charging for an additional visit, and what supports the level assigned to it? A billing employee may see both an extra E/M line and a level that the clinician’s record cannot explain. The Toccoa allegations connect those separate representations about the care.

Hudson Valley and the Work Behind the Signature

Hudson Valley Hematology-Oncology admitted billing additional E/M services without documentation of significant, separately identifiable work alongside chemotherapy, injections or venipuncture. Its court-approved civil settlement with the United States fixed the principal payment at $5,314,000. The settlement also addressed other conduct, including routine copayment waivers.

The whistleblower was a former accounts-receivable representative responsible for coding and charge entry. Schedules, the personnel who actually treated patients, physician signatures and transmitted claims showed different stages of the billing process. For someone in that role, the important comparison reaches beyond the signed note to who provided the care and what the practice billed for it.

Vohra Wound Physicians and Automatic Modifier 25 Claims

Automatic Modifier 25 fraud can begin with the software rule that produces the claim. The Justice Department’s complaint against Vohra Wound Physicians alleged that its proprietary medical-record system restricted physicians’ entries, forced choices from preset options and generated documentation to support Medicare billing. Its allegations included an automatic extra visit claim when a physician recorded something about another wound:

The complaint also alleged that management set revenue goals, worked backward to the combinations of services needed to meet them and pressured physicians to deliver those services. The complaint described an outside audit that found a 30.85% error rate in E/M services billed with the modifier. According to the complaint, senior management received the results but did not return overpayments or immediately correct the system.

Vohra Wound Physicians and its owner agreed to a $45 million settlement in November 2025, resolving allegations that also included unnecessary debridements and routine care billed as surgery. The alleged software mechanism explains why a signed medical record can be an incomplete answer to a billing question. We see the absurdity in a system that demands a notation, then treats the existence of that notation as the reason to charge for more care. A prompt becomes a payment.

Healogics and the Prescription Inside the Procedure

Healogics agreed to a $398,163 civil settlement announced in June 2018 to resolve the Justice Department’s allegations that Modifier 25 represented separate E/M services that were not performed on procedure days. The claims involved Medicare, Medicaid and TRICARE. A private citizen brought the whistleblower case.

The whistleblower’s complaint alleged a specific trigger: when a physician prescribed an antibiotic as part of debridement, a staff member added a Level III E/M claim using the modifier. It also described a centrally created corporate coding manual. The prescription was part of the procedure record, but the alleged billing practice turned it into another visit charge. That is a concrete connection an insider can recognize between clinical documentation and a coding instruction.

What Evidence Does a Whistleblower Need?

We assess what you already know and hold to connect the added E/M claim to the actual care and the decisions that produced the bill. Clinical records, billing instructions and software settings can tell different parts of the story, and we work through those differences with you.

The Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, published in 2017, describes checking treatment dates, treatment types and nurse or physician signatures. It then makes the point that matters when a record contains words the software supplied:

An employee may know which language the clinician entered and which language appeared automatically. A coder may know who required the added claim. A billing manager may know what happened after an audit identified the problem. Vohra’s alleged system behavior and Hudson Valley’s schedules and signatures show why those accounts belong beside the chart.

Written instructions can make the connection particularly clear. A whistleblower complaint against City Practice Group of New York concerning billing sheets alleged that employees were told which payers’ bills should carry the modifier without regard to whether the services were separate. That allegation concerns a direction applied across claims. We examine the instruction alongside the encounters, claims and people who can explain how it worked.

Why Auditors Look at Modifier 25

Modifier 25 can allow an E/M claim to pass Medicare’s automated edits for services billed on the same day as a procedure. In the May 2025 eye-injection audit, the inspector general found that 42% of injections in the June 2022 through May 2023 audit period had a same-day E/M claim with the modifier.

$123,955,176

Medicare payments for same-day E/M services billed with Modifier 25 alongside eye injections during the audit period.

Documentation for 22 of 24 sampled E/M services did not support the modifier.

Payments at risk, not a loss total.

Health and Human Services Office of Inspector General, eye-injection E/M audit, May 2025

The inspector general called for medical reviews to determine which payments should be recovered. During the period examined, Medicare contractors performed no prepayment or postpayment medical reviews of these modifier claims, and the inspector general found that the Centers for Medicare & Medicaid Services had not sufficiently clarified when the extra services were payable. A claim could pass through the payment system while the clinical documentation still failed to support the modifier. That explains why the paid claim and the underlying chart both matter.

Medical Upcoding: Is It a Billing Error or Fraud?

Knowingly billing a government program for an added visit that never happened can support a False Claims Act case. In an extra-visit case, instructions to add the charge, software that generates it and audit findings delivered to management can connect the unsupported service to the decision to keep billing.

Vohra’s complaint illustrates that connection through the alleged automatic claim and management’s response to the audit. Toccoa illustrates why the existence of a separate service and the level billed each need support. We work through those facts with the insider who understands the encounters and the billing process. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know How the Extra Visit Gets Billed

If you know who requires the extra E/M charge or how the software creates it, speak with our whistleblower experts about the claims you see. We use our knowledge of physician billing schemes to build your case around what happened inside the practice and who directed it. We stay beside you through the process and find healthcare billing whistleblower lawyers who know Modifier 25 cases.