Wiki Blue Cross and modifier 25

[aktulip11@hotmail.com]

Is anyone having issues billing modifier 25 and Blue Cross? We are having our claims denied for additional documentation, so we send in the documentation and documentation is not attached and claim is not reprocessed until I call to follow up on the claims. This is all very time consuming. We've never had to send in additional documentation when we've billed with modifier 25 before.

 

[amyjph]

Are you appending modifier 25 appropriately? Sounds like your group is on pre-payment review. Has anyone looked into that? Have you gotten audits for excessive modifier 25 use?
Is it "all" claims or just certain ones? Is the group orthopedic or dermatology? Is it preventive & problem visit on the same day? What is being billed? Is a 25 being appended to all E/M inappropriately?

Also, check your provider portal and/or news bulletins and policies for the plan you are billing to.
Examples: https://providernews.anthem.com/nev...nted-evaluation-and-management-services-13023

https://providernews.anthem.com/indiana/articles/policy-update-modifiers-25-and-57-2-12905

https://providers.anthem.com/docs/gpp/KY_CAID_RP_Modifier25and57EvalMgmtGlobalProcedures.pdf?v=202305191058

https://providernews.anthem.com/california/articles/update-regarding-evaluation-and-management-with-modifier-25-same-day-as-procedure-when-a-prior-em-for-the-same-or-similar-service-has-occurred-professional-1-1594

Example OIG report re: mod 25: https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
Example OIG work plan item: https://www.oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000577.asp

Other info: https://www.mgma.com/podcasts/ask-an-advisor-making-sense-of-modifier-25-and-modifier-57-denials

Modifier 25 fact sheet

www.novitas-solutions.com

https://www.ama-assn.org/practice-management/cpt/setting-record-straight-proper-use-modifier-25

 

[aktulip11@hotmail.com]

Thank you. I will look into those. It seems random right now, but I will keep watching it. We are a pediatric office.

 

[amyjph]

If it is a preventive visit and problem visit on the same day you need to check and make sure they are billed appropriately.
Search modifier 25 here: https://www.premera.com/ak/provider/news/payment-policies/policy-updates/february-2023/

https://www.premera.com/wa/provider/news/medical-policies/policy-updates/

 

[Cls1530]

Is anyone having issues billing modifier 25 and Blue Cross? We are having our claims denied for additional documentation, so we send in the documentation and documentation is not attached and claim is not reprocessed until I call to follow up on the claims. This is all very time consuming. We've never had to send in additional documentation when we've billed with modifier 25 before.

I work for an organization with a large number of outpatient providers who bill with the 25 modifier for patients with BCBS insurance. I have noticed they seem to do a TPE type of review for particular providers. Once they are satisfied that either the provider is billing correctly or the appeal supports the level of service, they move on to another provider(s).