CurrentCareSourcePolicy N/A

Modifier 25 — Arkansas PASSE

Defines CareSource's reimbursement and review stance for claims using CPT/HCPCS modifier 25 for Arkansas PASSE members; applies to providers submitting claims to CareSource and its affiliates.

Policy Summary

PayerCareSource

PolicyModifier 25 — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit documentation that substantiates a significant, separately identifiable E/M service when billing with modifier 25 to support reimbursement and avoid recovery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy applies to Arkansas PASSE (state-specific)

Modifier 25modifier addressed

Yesdocumentation required

99211CPT code excluded

Modifier 25 Coverage Criteria

Modifier 25 coverage criteria

Coverage contingent on documentation and not meeting listed inappropriate circumstances:

Documentation must substantiate the E/M service as significant, separately identifiable, and medically necessary; provider is responsible for submitting accurate and complete documentation.

Use AMA CPT and CMS guidance to determine whether E/M criteria are met.

Modifier 25 is inappropriate when ANY of the following apply:

The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure (major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period).
The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure.

Policy Summary

PayerCareSource

PolicyModifier 25 — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionSubmit documentation that substantiates a significant, separately identifiable E/M service when billing with modifier 25 to support reimbursement and avoid recovery.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding Guidance and Exclusions

Explicit exclusionCPTNot Covered

99211

CPT 99211 will not be reimbursed when billed with modifier 25.

Documentation threshold — modifier 25

Documentation requirementDocumentation must substantiate a significant, separately identifiable E/M service meeting the E/M criteria; use AMA CPT and CMS guidance to determine level and medical necessity.

Provider responsibilityProvider must submit medical record documentation upon CareSource request to support modifier 25 use.

Scope of documentationDocumentation must show the E/M was above and beyond usual preoperative/postoperative care and medically necessary; different diagnosis is not required.

Review triggersClaims may be subject to prepayment clinical validation or post-payment audit; unsupported documentation may lead to denial or recovery.

Provider Billing and Review Actions

Prior Authorization

Prepayment and Post-payment Review

Claims billed with modifier 25 may be flagged for prepayment clinical validation or prepayment medical record coding review. For prepayment review, once the claim has been clinically validated it is either released for payment or denied for incorrect use of the modifier. For post-payment review, a decision is made based on the submitted documentation and unsupported claims may be recovered.

Prepayment clinical validation or prepayment medical record coding review may be initiated.
Prepayment: claim is released for payment or denied after clinical validation.
Post-payment: unsupported claims may be recovered if documentation does not support the claim.
Providers are responsible for submitting accurate documentation to substantiate the claim.

Denial Risk

Appeals for Review Findings

Standard appeal rights apply for findings from both pre- and post-payment reviews; providers may use the normal appeals process following the outcome of the review.

Appeal rights apply whether a claim is denied during prepayment validation or after post-payment review and recovery.

Definitions

Modifier 25 — definition

DefinitionModifier 25: used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.

PurposeIndicates a significant, separately identifiable E/M service in addition to another service on the same day.

Documentation noteThere must be documentation in the medical record that substantiates the use of modifier 25.

Modifier — definition

DefinitionModifier: a 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered.

FunctionProvides context about altered circumstances of a service (e.g., multiple procedures, distinct E/M).

Use with codesAppended to CPT® or HCPCS codes; CareSource may verify modifier use through prepayment or post-payment review.

CPT / HCPCS — definitions

CPTCurrent Procedural Terminology (CPT®) — codes issued, updated, and maintained by the American Medical Association to code and bill medical services and procedures.

HCPCSHealthcare Common Procedure Coding System (HCPCS) — codes used to code products, supplies, and services not included in CPT® codes.

AuthorityCareSource uses published CPT® and CMS guidelines to determine correct code and modifier use.