Modifier 25 Reimbursement Reduced

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By: Lorna Simons, CPC
Medco Consultants, Inc

Have you noticed reduced reimbursements for your Evaluation and Management (E/M) visits with Modifier 25 appended? For years 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, has been on the Office of Inspector General’s (OIG) workplan for inappropriate use and overutilization.  In response to utilization concerns, Independence Health Group (IBX), who has subsidiaries in multiple states, reduced the reimbursement for E/M visits when the modifier is appended to 50% of the fee schedule/contracted rate.

According to IBX’s Modifier 25: Frequently asked questions, effective 8/1/17, the new policy will affect their Commercial and Medicare advantage plans when performed with a minor surgical procedure or preventive visit. Providers participating in the plans affected by the reimbursement change will not be able to dispute the reimbursement changes as it is part of their policy. 

It is always important to check with the insurance carrier’s policy when noticing a change in your reimbursement rate. If the policy states the insurance carrier reimburses for Modifier 25 at a regular or reduced rate and you notice changes or denials, contact your provider representative for additional information.