Modifier-25 audit defended — $ 80k clawback denied.
A dermatology practice faced an $80k payer clawback over modifier-25 usage. We defended every claim in the audit sample and the payer withdrew the recoupment entirely.
$ 80k
Clawback denied
$ 80k
Clawback denied
100%
Of sampled claims defended
0
Recoupment paid
9.6% → 6.1%
Denial rate
The challenge
A commercial payer launched a modifier-25 audit and demanded an $80k recoupment, claiming same-day E/M services weren't separately identifiable. Foothill's documentation existed but wasn't organized to defend it.
What we did
- Pulled and organized the documentation for every claim in the audit sample.
- Built a claim-by-claim defense showing the separately identifiable E/M.
- Responded to the payer within the appeal window with a clean evidence package.
- Tightened go-forward documentation so the modifier 25 is audit-proof.
"They turned an $80,000 problem into a non-event. The defense package was so thorough the payer just dropped it."
LB
Dr. Lena Brooks
Founder, Foothill Dermatology
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