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Claim Reimbursement Update: E&M Codes Appended with Modifier 25

Effective August 1, 2022, Horizon will change how we consider certain Evaluation and Management (E&M) codes included on professional claims for reimbursement.

These changes are based on revisions to the Evaluation & Management Edits subsection of our ClaimsXten Editing Rules reimbursement policy.

Currently, when an E&M service appended with Modifier 25 is submitted for the same date of service as another procedure code (or codes) that represent services that have a global surgical period of 0, 10 or 90 days, our claim processing system considers the E&M service at 100 percent of the appropriate Horizon allowance.

Beginning on August 1, 2022, we will consider E&M services appended with Modifier 25 at 50 percent of our appropriate Horizon allowance (or at the provider’s submitted charges if less) if one or more procedure codes that have a global surgical period of 0, 10 or 90 days are included on the same claim or on another claim for that same date of service.

This change will impact all claims processed August 1, 2022 and after for services provided to patients enrolled in:

  • Horizon fully insured commercial plans
  • Horizon Medicare Advantage plans
  • Braven Health℠ Medicare Advantage plans
  • Administrative Services Only group employer plans, including the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP)
Published on: May 2, 2022, 05:05 a.m. ET
Last updated on: April 28, 2022, 09:21 a.m. ET