News Alert: Turmoil Expected with Modifier 25

Expect changes regarding certain evaluation and management codes for reimbursement.

Effective Aug. 1, Horizon will change how we consider certain evaluation and management (E&M) codes included on professional claims for reimbursement.

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

Beginning on Aug. 1, however, there will be significant cuts to reimbursement for physicians in these scenarios. Horizon Blue Cross of New Jersey and its affiliates under their Medicare Advantage plans, Braven Health, and New Jersey state plans, will consider E&M services appended with Modifier 25 at 50 percent of the 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).

In late May, Cigna announced that it will begin requiring the submission of medical records with all E&M claims with CPT codes 99212-99215 and Modifier 25 when a minor procedure is billed.

Modifier 25 allows separate payment for a significant, separately identifiable E&M service provided on the same day as a minor procedure or other reported healthcare service. The updated Cigna policy will become effective nationwide on Aug. 13.

Failure to submit the required medical records will result in a denial.

Programming Note: Listen to Terry Fletcher’s live report on this developing story today during Talk Ten Tuesdays at 10 Eastern.