Provider Alert: Modifier 25 Payment Policy Addendum
Processing Issue
After we sent the Provider Alert on February 9, we discovered that additional services are incorrectly receiving payment reductions during our assessment of billing for preventative exams and problem-oriented E/M services when applying Modifier 25. We are currently testing configuration changes to fix this issue and will update you on the progress of all affected claims this week.
Same day evaluation and management and preventive exam visits:
When a preventive examination and a problem-oriented E/M service are reported on the same day for the same patient, the problem-oriented E/M service is reimbursed at 50% of the allowed amount regardless of the code appended with Modifier 25.
Preventative medicine codes:
- 99381-99397 (Preventive medical exam)
- G0402 (Preventive physical examination)
- G0438-G0439 (Annual wellness exam)
Problem-oriented E/M codes:
- 99201-99215
Per CPT guidelines, Modifier 25 (a 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 required to be billed in conjunction with the problem-oriented visit evaluation and management code when a preventive medicine service is reported on the same day for the same patient.
Sincerely,
Your Sentara Health Plans Team