Community First Health Plans is providing guidance on the appropriate use of Modifier 25 when reporting evaluation and management (E/M) services performed on the same date as a preventive medical visit.
Proper use of Modifier 25 supports accurate claims processing, compliance with coding standards, and reduces the likelihood of claim denials or payment recoupments.
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 that a distinct, separately identifiable acute care service was provided in addition to the preventive visit.
The acute service must be supported by a separate diagnosis and reflect the appropriate level of care. Use of Modifier 25 indicates that the service provided goes beyond the routine components of a preventive visit.
Documentation Requirements
Medical record documentation must support the use of Modifier 25 and clearly demonstrate:
- Medical necessity for the additional E/M service
- A diagnosis distinct from preventive codes (Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129)
- The level of E/M service reported
- Evaluation, treatment, and management of the condition
Documentation must be retained and made available upon request.
bILLING gUIDELINES
Preventive services must be reported with the appropriate preventive service codes, and the acute care visit must be reported with an E/M code appended with Modifier 25. Diagnoses submitted on the claim must clearly distinguish the preventive service from the acute condition being treated.
Non-Reimbursable Scenarios
Services addressing minor or trivial conditions that do not require additional evaluation or treatment beyond the preventive visit are not separately reimbursable. In these cases, the services are considered part of the preventive visit and may be subject to denial or recoupment if billed separately.
aDDITIONAL cONSIDERATIONS
If a condition requires evaluation or management beyond what is performed during the preventive visit, a separate E/M service may be billed when appropriately documented, or the patient may be referred for additional care.
Key Takeaway
Modifier 25 should be used only when a significant, medically necessary, and separately identifiable E/M service is performed and properly documented. Incorrect or unsupported use of Modifier 25 may result in claim denials or payment adjustments.
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.
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