Clarification on recent notice regarding modifier 25
Posted on February 8, 2011
Dear Provider:
Recently, we sent you a notice that described our new modifier 25 payment policy. Based on your feedback, we would like to provide additional details about the policy.
The modifier 25 policy applies primarily to Primary Care Physicians (PCPs) and Pediatricians. It involves a limited set of codes when these codes are billed together – specifically, preventive codes and problem focused E & M codes. When billed together, the E&M codes should have the modifier 25 appended, and payment for that code will be reduced by 50% of your contracted rate. Payment for the preventive code will be reimbursed 100% of your contracted rate. This new payment policy only applies to specialists when billing a preventive code and problem focused E&M code together.
The grid below shows examples of both correct coding and reduction, and incorrect coding and reduction. Providers may submit a corrected claim with the modifier only on the E & M line, not on the Preventive line.
|
|
Codes |
Modifier |
Reduction of contracted rate |
| Correct Billing | Preventive | None | None |
| E&M | 25 | 50% | |
| Incorrect Billing | Preventive | 25 | 50% |
| E&M | None | None | |
| Incorrect Billing | Preventive | 25 | 50% |
| E&M | 25 | 50% |
We apologize for any confusion this may have caused. If you have any questions, please contact Provider Relations at 413-233-3313 or toll-free at 800-842-4464, extension 5000 between the hours of 8:00 a.m. and 4:00 p.m., Monday through Friday.
