Use of modifier 25 when billing for visits that include preventive services and problem-oriented evaluation and management services

Beginning with claims processed on or after February 1, 2023, Empire BlueCross BlueShield HealthPlus will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99385-99387 or 99395-99397) is billed with a problem-oriented E/M service (CPT codes 99202-99215) and appended with modifier 25 (for example, CPT code 99395 billed with CPT code 99213-25).   

According to the American Medical Association (AMA) CPT Guidelines, E/Ms must be significant and separately identifiable in order to appropriately append modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service. 

Providers who believe their medical record documentation supports a significant and separately identifiable E/M service should follow the claims payment dispute process (including submission of such with the dispute) as outlined in the Provider Manual.

If you have questions on this program, contact your contract manager or Provider Experience representative.