Purpose
This billing guide outlines the appropriate use of Modifier 25 when reporting evaluation and management (E/M) services performed on the same date as a preventive medical checkup.
Policy Overview
Providers may be reimbursed for both a preventive checkup and an acute care E/M visit performed on the same date of service when criteria are met, including same provider/group billing, no similar services in prior three years for new patients, and that the acute service is significant and medically necessary.
Modifier 25 Requirements
Modifier 25 must be appended to the E/M procedure code to indicate a distinct, separately identifiable acute care service in addition to the checkup. The service must be supported by a different diagnosis and appropriate level of care.
Documentation Requirements
Medical records must support medical necessity, include a distinct diagnosis beyond preventive codes (Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129), reflect the level of E/M service, and include treatment details. Documentation must be retained and available upon request.
Documentation Requirements
Report preventive services with appropriate preventive codes and acute care services with an E/M code appended with Modifier 25. Diagnoses must distinguish services clearly.
Non-Reimbursable Scenarios
Minor or trivial conditions that do not require additional evaluation beyond the preventive visit are not eligible for separate reimbursement and may be subject to recoupment.
Non-Reimbursable Scenarios
If a condition requires further evaluation beyond the preventive visit, a separate E/M service may be billed or the patient may be referred for further care.
Key Takeaway
Modifier 25 should only be used when a significant, medically necessary, and separately identifiable E/M service is performed and properly documented.
Action:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter