D. had a herniated disk follow-up — same orthopedist, same office, same posture-check the doctor had done every six months for two years. The visit lasted nine minutes; the doctor sent him to imaging across the hall for an MRI. The bill that came back had two line items: the MRI itself ($2,140) and a separate E/M visit (CPT 99213) tagged with modifier 25 ($940).
Modifier 25 is the "yes the office visit should be billed separately on top of the procedure" claim. It's only valid when the office portion is a "significant, separately identifiable" E/M service beyond the routine pre-procedure evaluation. D. requested his own clinical note from the visit. The note had four sentences: pain status, posture observation, referral to MRI. No separate condition addressed, no new diagnosis, no E/M service that wasn't already wrapped into the MRI prep.
Audra's audit cited NCCI Policy Manual Chapter I, Section E.7 — the explicit definition of when modifier 25 is and isn't appropriate. The appeal letter went to the practice's billing department with the chart note attached as evidence. They withdrew the $940 line item the same week without a second exchange.