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Two Major Payers Change Modifier 25 Policies

One of the Country’s Major Payers will now need a new diagnosis for E/M payment.

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Modifier 25 (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) is used very frequently to justify a separate payment for E/M visits done with procedures. However, one of the major payers has indicated that they will not make payment for these services.

CPT Codes with Global Period of 0, 10, and 90 Days

Modifier 25 indicates that the billed E/M is significant and separately identifiable from the procedure performed at the same visit. However, some payers do not accept modifier 25. Tufts Health Plan announced on their website that effective for visits on or after July 1, 2014, they would not compensate for evaluation and management services with modifier 25 on the same day as a procedure with global period.

Where is it Applicable?

Tufts’ new policy is applicable to all of the situations where a surgery with 0, 10, or 90 days global periods and an office visit for an established patient was perfumed. Both for the same complaint for which there was prior visit within the past two months. A separate and significant E/M visit with a new diagnosis, however, should still be payable with modifier 25.

Exceptions

This rule is not applicable to new patients, ED and xxx global procedure services with E/M codes. Make sure that you use the modifier 25 only when it is required. Overuse of the modifier will land your practice in payer audits. Arkansas Medicaid has also tweaked their modifier 25 policy and the new policy is effective from May 2014.

ResourceRead the Tufts Health Plan announcement on modifier 25 on their website http://www.tuftshealthplan.com/providers/provider.php?sec=news&content=modifier_25.

To read the Arkansas Medicaid announcement visit http://www.medicaid.state.ar.us/InternetSolution/Provider/newprov.aspx.