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

On July 1, 2022, we communicated that HealthKeepers, Inc. would begin to implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service is billed with a problem-oriented E/M service and appended with modifier 25 (Provider News article). We have since decided to limit this review for claims for members aged 22 and older. Subsequently, we have updated the impacted CPT^® codes. For your convenience, we are including an updated communication below:

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 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). This review is limited to claims for members aged 22 and older.

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 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) outlined in the provider manual.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at  800-901-0020.