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

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

Beginning with claims processed on or after August 1, 2022, HealthKeepers, Inc. will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT^® codes 99381 to 99397) is billed with a problem-oriented E/M service (CPT codes 99202 to 99215) and appended with Modifier 25 (for example, CPT code 99393 billed with CPT code 99213 to 99225).

 

According to the American Medical Association (AMA) CPT Guidelines, E/M services 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 that 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.

 

AVA-NU-0580-22