Part B Insider (Multispecialty) Coding Alert

Reader Question:

Some Payers May Want Modifier 25 Despite Add-on Nature

Published on Mon Feb 29, 2016

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Question: United Healthcare recently denied a claim, saying that we should have added modifier 25 to our prolonged service add-on code +99354, which we had reported with 99215 for the same date of service. I was under the belief that add-on codes do not need modifiers and merely need to be reported with a base code. In addition, there doesn’t appear to be any Correct Coding Initiative (CCI) edits barring me from billing these codes together. Can you advise?

Codify Subscriber

Answer: Although in theory you are correct that add-on codes can only be billed with their base codes, the reality is that insurers sometimes make their own rules on this subject, and often do. Although United Healthcare doesn’t specifically say that 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) must be appended to your add-on prolonged service code, the payer doesn’t discourage the practice, either.

In its “Prolonged Services Policy” document, United Healthcare states, “According to CPT^®, modifier 25 may be appended to prolonged service codes if there is adequate supporting documentation that describes the service provided and indicates the service is significant and separately identifiable from another service or procedure on the same date of service.” Although this could apply to any other service in addition to the prolonged service code, UHC does not specifically clarify that you should abstain from using modifier 25 with prolonged service codes that are only being billed with “parent” E/M codes.

Therefore, you may want to check in with United Healthcare and ask if this is part of a broader policy that the payer is implementing so you can confirm it in your records for the future. If it’s not and it’s simply a mistake on UHC’s end, they should acknowledge that as well.