Correct Usage of Modifier 25

Date Issued: 8/27/2015

EmblemHealth is committed to correct coding and implementing programs that result in fair, widely recognized and transparent payment policies. From time to time EmblemHealth evaluates the coding practices of our Network providers for HIP, GHI HMO and Vytra, using recognized policy sources* As a result of these reviews, EmblemHealth has identified non-conforming use of Modifier 25. Based on the outcome of our claims review, your payment may be adjusted if the information submitted does not support the appropriate use of Modifier 25.

AMA CPT describes and defines the use of Modifier 25 as follows:

Description: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.Definition: It may be necessary to indicate that on the day a procedure or service was performed, as identified by a CPT code, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guide for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding Modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery, See Modifier 57.  For significant, separately identifiable non-E/M services, see Modifier 59.

To avoid any payment adjustments, we recommend you apply the definition for use of Modifier 25 when coding your claims, in addition to carefully documenting each service provided. Accurate coding translates clinical documentation into uniform diagnostic and procedural data sets and provides the evidence that the services billed were rendered to the patient.

Disputing a Claim Determination

If you do not agree with a payment determination, you have the right to file a grievance. You must first submit the portion of the medical record that supports additional reimbursement. We will review the submitted medical record(s) to assess the guidelines used and medical documentation to support the use of Modifier 25. EmblemHealth will adjust those claims where documentation substantiates the use of this modifier.

For additional details on grievance rights, refer to the “Practitioner Dispute Resolution Procedures: Complaints and Grievances” section of the EmblemHealth Provider Manual. Please review the chapters that apply to the following member benefit plans:

• Commercial and Child Health Plus Plans
• Medicaid Managed Care and Family Health Plus Plans
• Medicare Plans

Additional Resources

• Below are links to CMS definitions/instructions for Modifier 25:
  • https://palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~8EELF54813
  • palmettogba.com/palmetto/webTool.nsf/vTool/mod25
  • cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5025.pdf
• These links provide further information about Modifier 25:
  • ngsmedicare.com/ngs/poc/ngsmedicare1dmy&urile=wcm%3apath%3a%
    2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPolicy%2FPolicy%
    2BEducation%2BTopics%2FModifiers%2FModifier%2B25&LOB=Part%20B&
    LOC=New%20York&ngsLOC=New%20York&ngsLOB=Part%20B&jurisdiction
    =Jurisdiction%20K
  • fortherecordmag.com/news/022112_exclusive.shtml

Questions?

If you have questions, please sign in to emblemhealth.com to use our Message Center. Select “General Information” from the drop-down menu on the “Ask a Question” page.

*Policy sources include, but are not limited to, AMA and CMS policy regarding reimbursement of E/M services submitted with Modifier 25, as well as EmblemHealth’s plan-specific requirements (Refer to the Claims Review Software section of the Claims chapter of the EmblemHealth Provider Manual for additional information about claims review software used by EmblemHealth).