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Evaluation/Management Services (Modifier 25) Payment Policy Policy

Network Health covers evaluation/management (E/M) services billed with Modifier 25 for Network Health Together® (MassHealth), Network Health Forward® (Commonwealth Care), and Network Health Extend (Medical Security Program) members when medical records indicate that significant, separately identifiable services were performed on the same day. If medical records do not indicate that significant, separately identifiable services were performed, Network Health covers the primary procedure or other service, and denies the secondary E/M billed with Modifier 25. Network Health also covers therapeutic, prophylactic, and diagnostic injections and IV infusions (Current Procedural Terminology (CPT) codes 96360 ­ 96379), along with primary E/M services with documentation indicating that significant, separately identifiable services were performed on the same day. Without such documentation, Network Health covers primary E/M services and denies all therapeutic, prophylactic, and diagnostic injections and IV infusions performed on the same day. As an exception to this rule, Network Health will cover therapeutic injection codes used for the injection of ceftriaxone, in addition to the E/M service.

Definition

As defined by the American Medical Association, Modifier 25 indicates a significant, separately identifiable E/M service performed by the same provider on the same day as a procedure or other service. The significant, separately identifiable E/M service goes above and beyond the other service provided, or beyond the usual pre-operative and post-operative care associated with the primary procedure.

Billing and reimbursement

A provider may claim both an E/M service and a primary procedure by appending the Modifier 25 to the E/M service code. Modifier 25 should only be used for E/M service codes and not with surgery, global, or other service codes. To properly use Modifier 25, follow these four general guidelines: 1. Same day as procedure. Network Health will cover the use of Modifier 25 only for significant, separately identifiable E/M services performed by the same provider on the same day as a primary procedure or service that has global coverage or is otherwise bundled, according to the National Correct Coding Initiative (NCCI). 2. Significant, separately identifiable E/M service. A complaint, symptom, condition, problem, or circumstance, whether related or not to the primary procedure or other service provided, may prompt the need to perform an independent E/M service. 3. Adequate documentation of E/M service. Network Health follows standard global periods of 0, 10, or 90 days, depending on the service, where the E/M service for a typical member is usually already covered by the procedure code. A member's medical documentation must clearly show that the E/M service that was performed and billed was unique and distinct from the usual pre-operative and post-operative care associated with

____________________________________________________________________________________________________________________ This policy applies to Network Health Together, Network Health Forward, and Network Health Extend plans. Payment is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee payment. Network Health reserves the right to amend a payment policy at its discretion.

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the primary procedure performed on the date of service. An E/M service for an established visit requires two of three key components: history, examination, and decision-making. Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete and will result in a denial, with or without the Modifier 25. 4. Appropriate level of E/M service. The documentation should also reflect the level of E/M service being billed, including, but not limited to, CPT codes 99211 ­ 99215. Below are common mistakes in the use of Modifier 25: 1. Minor surgical procedures. Network Health does not reimburse for Modifier 25 when the services provided are part of the initial evaluation for a minor surgical procedure. The initial evaluation includes pre-operative evaluation services such as assessing the site or problem, explaining the risks and benefits of the procedure, and obtaining patient consent. 2. Chronic conditions. Network Health does not reimburse for Modifier 25 when a member has chronic conditions that are mentioned and reviewed without an explicit and significant added management component. 3. Pre- and post-operative services. Network Health only reimburses for Modifier 25 when the service is a component of a significant, separately identifiable E/M service. An E/M service does not include standard pre- and post-operative/procedural or service evaluations that are included in a global surgery/procedure or in the primary service identified by the Physician Fee Schedule and/or NCCI edits. 4. Incidental services. Network Health does not reimburse for medication using Modifier 25 when the service does not include key components of a problem-oriented E/M service, as medication is considered incidental to the primary service; a problem-oriented E/M service is not warranted in the absence of a substantive evaluation and management component. 5. Skin tag removal. Network Health does not reimburse for the office visit of the surgical service (definition of Surgical Package) of removing a skin tag, as the office visit is considered part of the pre-operative workup. The use of Modifier 25 is inappropriate when the E/M service is not unique and distinct from the usual pre-operative service. 6. Lesion removal. Network Health does not reimburse for Modifier 25 if the removal of a lesion is the sole purpose for a provider visit and the examination includes only the evaluation and removal of the lesion. The evaluation prior to removing the lesion is considered part of the pre-operative workup and is not significantly and separately reported.

____________________________________________________________________________________________________________________ This policy applies to Network Health Together, Network Health Forward, and Network Health Extend plans. Payment is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee payment. Network Health reserves the right to amend a payment policy at its discretion.

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