Office Visits - Use of Modifiers

Modifier 25 - Significant and Separately Identifiable Service

HMSA follows CPT guidelines for use of modifier 25. Modifier 25 will be recognized when appropriately appended to a significant, separately identifiable E&M service when billed in conjunction with another service or procedure performed by the same provider on the same day of the original service or procedure if the following criteria are met:

• The appropriate level of E&M service is billed.
• Modifier 25 is appended to the E&M service, which is above and beyond the other service or procedure provided (including usual preoperative and postoperative care associated with the procedure).
• The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly separate E&M service.
• The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevent separate reimbursement even if the E&M code is appended with a Modifier 25.

Modifier XE, XS, XP, XU, 59 - Distinct Procedural Services

HMSA follows CPT/HCPC guidelines for modifiers -X{ESPU} and 59 used for identification of distinct procedural services. These modifiers are used to identify procedures/services that are commonly bundled together but are appropriate to report separately under some circumstances. Prior to Jan 1, 2015, providers used modifier 59 for all of the scenarios listed below. With the creation of the X modifiers, providers are now able to further detail why the procedure or service is being identified as distinct. According to CPT guidelines, modifier 59 should be used only when no other descriptive modifier explains why distinct procedural circumstances exist. Therefore, these new modifiers should primarily be used instead of modifier 59 to describe why a service is distinct.

• XE - Separate Encounter: A service that is distinct because it occurred during a separate encounter.
• XS - Separate Structure: A service that is distinct because it was performed on a separate organ/structure.
• XP - Separate Practitioner: A service that is distinct because it was performed by a different practitioner.
• XU - Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service.

Evaluation and Management (EM) Services billed with Chiropractic Manipulative Therapy (CMT):

According to CPT guidelines, CMT codes include a pre- and post- manipulation patient assessment.

It may be appropriate to separately and additionally report an EM service with modifier 25 only in the following conditions:

1. Initial evaluation of a new member or condition, or a reevaluation of an established patient’s progress under a current treatment plan every thirty (30) days
2. Acute exacerbation of symptoms or a significant change in the member’s condition; or
3. A distinct and different indication which is separately identifiable and unrelated to the manipulation.

When reporting an EM service as separate to CMT for any of the three (3) reasons listed above, modifier 25 must be appended to the E&M code. If modifier 25 is not appended, the E&M service will not be reimbursed as it is considered routine and included within the CMT code.

It is not appropriate for an EM service to be routinely reported with CMT with modifier 25. The HMSA’s medical policy for Chiropractic Services further explains that EM visits with CMT are limited to one per month.

Retrospective Reviews

HMSA reserves the right to conduct prospective and retrospective reviews on services to ensure correct coding and that payment determination criteria has been met. As always, providers must maintain adequate documentation in the medical record. Documentation must support the modifier use for separate services. Although one of these modifiers may be appended to a claim line on first submission, this does not guarantee reimbursement for these services. Medical records may be required to validate use of modifier. E&M services that do not meet the above-listed criteria will be denied or subject to recovery.

Revision History