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AmeriHealth has updated its policy on Modifier 25 reporting and
reimbursement. Claim Payment Policy #03.00.06n: Modifier 25: 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 was posted as a Notification on May 1, 2017, and will go into
effect August 1, 2017.
As part of the update, there are two scenarios outlined within the policy
where a payment reduction of 50 percent will be applied to certain services
when appropriately billed with Modifier 25. This applies to all professional
Modifier 25 claim submissions with a date of service on or after August 1,
2017, that fall into these two scenarios:
- When Modifier 25 is appropriately appended to an evaluation and management
(E&M) service and is submitted on the same date of service, by the same
professional provider or other qualified health care provider, as a minor
procedure, the E&M service is reimbursed at 50 percent of the applicable fee
schedule amount.
- When Modifier 25 is appropriately appended to a problem-focused E&M service
and is submitted on the same date of service, by the same professional provider
or other qualified health care provider, as a preventive E&M, the
problem-focused E&M service is reimbursed at 50 percent of the applicable fee
schedule amount.
More information
To view the Notification for this policy, which includes further detail on
the two scenarios where the 50 percent Modifier 25 reduction will be applied,
visit our Medical Policy Portal
and select Accept and Go to Medical Policy Online. Then select
Commercial under Active Notifications.
If you have any questions, please contact your Provider Partnership
Associate or Network Coordinator.
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