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Modifiers are a big part of billing, coding, and claims processing. Modifiers allow us to share with insurance carriers’ information necessary to adjudicate claims for reimbursement. Some modifiers are scrutinized more than others because of the frequency in which they are used, and/or the misuse of certain modifiers. When reporting evaluation and management services, one modifier available to tell the story is modifier 25. It can only be used for sharing information related to codes 99202-99499. It tells the insurance company that the visit is a separately and significantly identifiable service from a procedure(s) that is also performed on the same date of service that has a 00 or 10 day post-operative period assigned to it. This is where the confusion comes in as to when it is or isn’t applicable.
The problem with modifier occurs when evaluation and management visit and procedure(s) are related. According to the NCCI Policy Manual published by CMS, there has to be a very unrelated procedure(s) performed in order to correctly apply the modifier 25. We will discuss not only different interpretations of this policy but will also look at real life examples for using Modifier 25 both right and wrong. Evaluation and management services are the number 1 service performed in offices, hospitals, and other healthcare facilities.
The real and full description of modifier 25 will be thoroughly reviewed to have a clear understanding of its purpose. Even when you believe the modifier was assigned to an evaluation and management visit correctly, it is very common to receive a claim denial when it is reported with a procedure(s). What you need to do to appeal that denial will be shared with proven results.
Who Should Attend
Coders, Billers, Denial Reps, Claim Adjusters, Case Managers
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