Sept. 3, 2015

Modifier 25 Reminders

When you submit a Blue Cross and Blue Shield of Oklahoma (BCBSOK) Provider Review Form requesting review of a previously submitted claim that contained Modifier 25, we will perform a retroactive audit to determine if the services rendered warrant use of this modifier. If we receive a request to add Modifier 25 to a previously submitted claim, medical records are required to complete our review. If appropriate documentation is not included, the Provider Review Form will be returned to you along with a request to include medical information explaining the reason for adding the modifier to a claim that was originally sent without one.

The Current Procedural Terminology (CPT^®) codebook defines Modifier 25 as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Remember these tips when using Modifier 25:

• Documentation must support significant and separately identifiable preoperative and/or postoperative work, above and beyond the usual care associated with the performed procedure.

• Documentation must support that the patient’s symptom, problem or condition required a separately identifiable E/M service.

• The reported E/M service must meet the key components (history, examination and complexity of medical decision making) of the selected E/M service.

• The E/M service must be distinct from the service performed.

• Modifier 25 should only be appended to E/M services and not procedures.

• Modifier 25 is not used to report an E/M that resulted in the decision to perform surgery. Refer to Modifier 57 guidelines for an E/M service which results in a decision for surgery.

• Procedures include preoperative evaluation services necessary prior to performing a procedure or other service. This may include, but is not limited to assessing the site/condition, explaining the procedure and obtaining informed consent.

Please refer to the CPT codebook for additional details.

As a reminder, BCBSOK actively participates in inquiries and investigations to accurately identify and appropriately address potential fraudulent activities through our Special Investigations Department (SID). The SID is committed to reducing health care costs and helping to protect the integrity of the BCBSIL independently contracted provider network.

To learn more about SID, we welcome you to view the SID tutorial located in the Education and Reference Center/Fraud and Abuse section of our website at bcbsok.com/provider.

CPT Copyright 2014 American Medical Association (AMA). All rights reserved.
CPT is a registered trademark of the AMA.
This material is for educational purposes only and is not intended to be a definitive source for what codes should be used for submitting claims for any particular disease, treatment or service. Health care providers are instructed to submit claims using the most appropriate code based upon the medical record documentation and coding guidelines and reference materials.