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The Modifier 25: FAQ document was updated on September 25, 2017. Please download the latest version and check back often for future updates.
As previously communicated, 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.
Clarifications to the Notification
To address questions regarding how we define a minor procedure, the following language was added to the Notification on May 9, 2017:
A minor procedure has a zero-day or a ten-day post-operative period.
In addition, a complete list of CPT? codes identifying a minor procedure can be found in Attachment A of the Notification. Attachment A and Attachment B also list the specific evaluation and management (E&M) service codes that fall under the 50 percent reduction scenarios.
Note: Procedures without a zero-day or ten-day post-operative period (e.g., immunizations and vaccines, and their associated administration services, as well as EKGs and pulmonary function testing) are not considered minor procedures and are not part of the 50 percent reduction of the Modifier 25 policy.
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 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.
A minor procedure has a zero-day or ten-day post-operative period.
- 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 service, 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.
For questions about these updates, please review our Modifier 25: Frequently Asked Questions (FAQ) documents for AmeriHealth New Jersey and AmeriHealth Pennsylvania, which can also be found on AmeriHealth NaviNet? Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, email us at modifier25providerquestions@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email.
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