Modifier 25 and E & M services

Multiple E&M services on the same day

• Reimbursement will be made for a preventive code with a problem focused code when modifier -25 is applied to the problem-focused code. Reimbursement for the preventive  service will be made at 100% of the contracted rate, and reimbursement for the problem focused service will be made at 50% of the contracted rate. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused E&M service. Members have no copayment and/or deductible for routine physical exams. Members will be responsible for a copayment and/or deductible when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.

• For all other services, FCHP allows one E&M code per day of service per physician group, per specialty regardless of the places of service.


E&M services submitted with Medicare annual wellness visit

Problem-focused E&M services will be allowed at 50% of the contracted rate when submitted with Medicare annual wellness visit codes G0438 or G0439 when modifier -25 is applied to the problem-focused code. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused service. Members will be responsible for a copayment when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.


E&M services provided with removal of impacted cerumen

FCHP does not reimburse removal of impacted cerumen (69210) when submitted when billed on the same date of service as E&M services.


E&M services provided with an office/outpatient procedure

• FCHP does not allow the separate reimbursement of E&M services when a substantial diagnostic or therapeutic procedure is performed. The “usual care” for the typical patient is already covered by the procedure.

• Append modifier -25 to the E&M service when a significant, separately identifiable E&M service is above and beyond the usual pre- and post-operative procedure rendered by the same physician on the same day as the procedure. Those services coded with modifier -25 will be reimbursed and will be regularly reviewed for coding accuracy.


E&M services provided with lab collection and screening services

• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.

• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.

• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will reimburse only non-OBGYN PCPs for G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will not reimburse separately for 36415 (collection of venous blood by venipuncture) and/or 36416 (collection of capillary blood specimen i.e., finger, heel, ear stick) when billed along with an E&M office visit (99201-05; 99211-15) or preventative medicine service (99381-87; 99391-97) or office-based lab Proceure  codes (i.e. CLIA waived tests).

• FCHP will not reimburse separately for 99000; 99001 (lab specimen handling services) when billed with an E&M office visit (99201-05; 99211-15) or preventive medicine service (99381-87; 99391-97).

• FCHP does reimburse 36415 when it is the sole service provided.

• FCHP does reimburse 36416 when it is the sole service provided.