CurrentAmbetter NevadaPolicy CC.PP.013

Clinical Validation of Modifier 25

Governs prepayment clinical review and reimbursement decisions for Evaluation & Management (E/M) services billed with Modifier 25 for Ambetter Nevada members; affects providers submitting claims with Modifier 25.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Validation of Modifier 25

Policy CodePolicy CC.PP.013

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateNov 14, 2025

Key ActionProvide supporting medical records on appeal if a Modifier 25 claim is denied after prepayment clinical validation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prepaymentclaims flagged for clinical validation

4criteria examples that support Modifier 25 reimbursement

allowedappeal pathway

AMA/CMS/OIGguidance sources cited

Documentation & Reimbursement Criteria

Documentation and reimbursement criteria for Modifier 25

Policy Summary

PayerAmbetter Nevada

PolicyClinical Validation of Modifier 25

Policy CodePolicy CC.PP.013

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateNov 14, 2025

Key ActionProvide supporting medical records on appeal if a Modifier 25 claim is denied after prepayment clinical validation.

SourceLink

On This Page

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Documentation must substantiate a significant, separately identifiable E/M service for the service reported; if claim history or diagnosis codes do not indicate a separately identifiable service, the primary procedure will be reimbursed and the E/M billed with Modifier 25 will be denied.

Providers should assign all applicable diagnosis codes that indicate the need for additional E/M services.

ONE of

The E/M is the first time the provider has seen the patient or evaluated a major condition
A diagnosis on the claim indicates a separate medical condition was treated in addition to the procedure performed
The patient’s condition is worsening as evidenced by diagnostic procedures being performed on the date of service
Provider bills supplies/equipment on the same date that are unrelated to the procedure performed but would require an E/M service to determine the patient’s need

For minor surgical procedures with global periods of 000 or 010 days, the decision to perform the procedure is included in the procedure value; a separate E/M is reportable with Modifier 25 only if the E/M is significant and separately identifiable and unrelated to the decision to perform the minor procedure (patient new-to-provider status alone is not sufficient).

Modifier and NCCI Guidance

ModifierModifierCovered

25	Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service

NCCI global period guidance (000/010) — when separate E/M is reportable

Scope of NCCI global period guidanceMinor surgical procedures with global periods 000 or 010 are defined as minor; the decision to perform the procedure is included in the procedure value and should not be reported separately as an E/M.

When separate E/M may be reportableA significant, separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with Modifier 25.

New patient statusPatient being 'new' to the provider alone is not sufficient to justify reporting an E/M on the same date as a minor surgical procedure.

Diagnosis requirementThe E/M service and minor surgical procedure do not require different diagnoses to report the E/M separately.

Prepayment Validation & Appeals

Note

Prepayment clinical validation and appeals for Modifier 25

Code auditing software flags all claims billed with modifier 25 for prepayment clinical validation. Once validated, the claim will be released for payment or denied if modifier use is incorrect. If a claim is denied for insufficient documentation supporting Modifier 25, the provider may submit an appeal/reconsideration with all pertinent medical records for the date of service and procedures billed; do not submit records with the initial claim because initial review only considers information on the claim and member/provider history.

Claims billed with Modifier 25 are flagged for prepayment clinical validation.
If documentation is insufficient, the provider will receive a denial on the EOP.
Providers may submit an appeal/reconsideration with all pertinent medical records for the date of service and procedures billed.
Medical records should not be submitted with first-time claims; submit records only for denials when requesting reconsideration or appeal.

Key Definitions

Significant, separately identifiable E/M service — Modifier 25

Definition (Modifier 25)Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Key qualifierThe E/M must be 'above and beyond' the services associated with the procedure or beyond usual pre- and postoperative care.

Guiding sourcesPolicy references AMA CPT, CMS, and OIG guidance for appropriate use of Modifier 25.

Prepayment review noteClaims billed with Modifier 25 are subject to prepayment clinical claim review to determine correct use.