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Updated policies on Modifier 25 reporting and reimbursement

May 1, 2017

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Independence has updated its policies on Modifier 25 reporting and reimbursement. The following policies were posted as Notifications on May 1, 2017, and will go into effect August 1, 2017:

  • Commercial: #03.00.06n: 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
  • Medicare Advantage: #MA03.003c: 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

As part of the update, there are two scenarios outlined within the policies where a payment reduction of 50 percent will be applied to certain services when appropriately billed with Modifier 25. This applies to all professional Modifier 25 claim submissions with a date of service on or after August 1, 2017, that fall into these two scenarios:

  • When Modifier 25 is appropriately appended to an evaluation and management (E&M) service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
  • When Modifier 25 is appropriately appended to a problem-focused E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M, the problem-focused E&M service is reimbursed at 50 percent of the applicable fee schedule amount.

More information

To view the Notifications for these policies, which include further detail on the two scenarios where the 50 percent Modifier 25 reduction will be applied, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select either Commercial or Medicare Advantage under Active Notifications.

If you have any questions, please contact your Network Coordinator.

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