Modifier 25

Reimbursement Policy:

Modifier 25

Effective Date:

August 1, 2006

Revision Date:

MAY 1, 2015

Purpose:

Provide guidelines for the recognition of modifier 25 when appropriately appended to Evaluation & Management (E&M) services for participating and nonparticipating providers.

Scope:

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g., Medigap)
  • COB.

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:

Horizon BCBSNJ recognizes modifier 25 when appropriately appended to a significant, separately identifiable E&M service when billed in conjunction with another service or procedure performed by the same provider on the same day of the original service or procedure if the following criteria are met:

  • The appropriate level of E&M service is billed.
  • Modifier 25 is appended to the E&M service, which is above and beyond the other service or procedure provided (including usual preoperative and postoperative care associated with the procedure).
  • The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly separate E&M service.
  • The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevent separate reimbursement even if the E&M code is appended with a Modifier 25.

E&M services that do not meet the above-listed criteria will be denied.

Horizon BCBSNJ’s reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the significant, separately identifiable E&M service performed by the same provider on the same day of the original service or procedure based on the above criteria.

Beginning with date of service August 1, 2014, Horizon BCBSNJ does not provide reimbursement for E&M services appended with modifier 25, based on what is considered ineligible based on our Claim Editing Policies.

Participating physicians and other health care professionals can review how our claim editing policies impact reimbursement for code combinations by using the McKesson Clear Claim ConnectionTM tool available online from the Horizon BCBSNJ Plan Central page in NaviNet.

Horizon BCBSNJ reserves the right to perform post payment review of claims submitted with Modifier 25.

This policy recognizes that the services below, performed on the same day by the same provider, are performed once, rather than twice:

  • Scheduling of the patient.
  • Taking and documenting the patient’s history.
  • Taking and documenting the patient’s vital signs.
  • Use of the examination room.
  • Generation and or mailing of the bill and collection of the requisite copayments/coinsurance, etc.

Procedure:

Recognize and consider for reimbursement a significant, separately identifiable E&M service performed by the same provider on the same day of the original service or procedure when appropriately billed with modifier 25. However, Horizon BCBSNJ will not provide reimbursement and will not override the incidental edit for E&M services appended with modifier 25, based on what is considered ineligible as outlined within Horizon BCBSNJ’s claim editing policies.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
  • Mandated or legislative required criteria will always supersede

Policy 021_v2.0_05012015