Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 03.00.06p


Attachment:B

Policy #:03.00.06p

Description:Problem-focused E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M.

Title: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


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



The problem-focused E&M codes, listed in Table 1 below, are reimbursed at 50 percent of the applicable fee schedule amount when appended with modifier 25 and submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M. A list of preventive E&M codes is found in Table 2.

Table 1. Problem-Focused E&M Codes

Problem-Focused E&M Code
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
G0463


The problem-focused E&M codes, listed in Table 1 above, are reimbursed at 50 percent of the applicable fee schedule amount when appended with modifier 25 and submitted on the same date of service, by the same professional provider or other qualified health care provider. A list of preventive E&M codes is found in Table 2.

Table 2. Preventive E&M Codes

Preventive E&M Codes
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
G0402
G0438
G0439



Version Effective Date: 01/01/2019
Version Issued Date: 02/13/2019
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.