CurrentCareSourcePolicy N/A

Modifier 25 reimbursement guidance

This CareSource reimbursement policy governs appropriate use, review, and reimbursement considerations for CPT modifier 25 for Arkansas PASSE providers; it affects submitting providers billing CareSource for same-day evaluation and management (E/M) services performed with another service or procedure.

Policy Summary

PayerCareSource

PolicyModifier 25 reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionEnsure documentation substantiates a significant, separately identifiable E/M service beyond usual pre/post-operative care when billing with modifier 25.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/01/2025policy effective date

Arkansas PASSEapplicability program

99211 excludedspecific denial rule

Pre/post reviewclaim review processes

Modifier 25 Coverage Criteria

Modifier 25 coverage criteria

Reimbursement is allowed only when documentation, coding, and applicable guidance support the modifier; CareSource may review and recover payments if use is unsupported.

Modifier 25 may only be used when documentation supports a significant, separately identifiable evaluation and management (E/M) service by the same provider on the same day as another procedure or service.

Documentation must substantiate that the E/M service is beyond usual pre-operative or post-operative care; routine or unsubstantiated use is inappropriate.

Inappropriate when any of the following apply:

The E/M service is within usual pre- or post-operative care.
The E/M service was performed on a different day than the procedure or other service.

Policy Summary

PayerCareSource

PolicyModifier 25 reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionEnsure documentation substantiates a significant, separately identifiable E/M service beyond usual pre/post-operative care when billing with modifier 25.

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 Rules and Documentation Standards

Explicit code-level ruleCPTNot Covered

99211

CPT 99211 will not be reimbursed when billed with modifier 25

Documentation standard — substantiation for modifier 25

Documentation requirementDocumentation must substantiate a significant, separately identifiable E/M service beyond usual pre‑operative and post‑operative care to support use of modifier 25.

TimingModifier 25 applies when the E/M service is provided by the same physician or qualified health care professional on the same day as another procedure or service.

ExclusionNot appropriate to report modifier 25 for an E/M service that resulted in the decision to perform surgery (see modifier 57).

Provider responsibilitySubmitting providers must supply accurate and complete documentation; failure to do so may result in denial or recovery of payment.

Review processesClaims with modifier 25 may be subject to prepayment clinical validation, prepayment medical record coding review, or post‑payment review with potential payment recovery.

Claims Review, Audit, and Provider Responsibilities

Denial Risk

Claim review and audit

CareSource may review claims at any time to ensure correct coding and guideline compliance. Claims billed with modifier 25 may be flagged for prepayment clinical validation or a prepayment medical record coding review. For prepayment review, once clinically validated the claim will be either released for payment or denied if the modifier is used incorrectly. For post-payment review, CareSource will make a determination based on the submitted documentation; if the documentation does not support the claim, CareSource may recover the payment when applicable.

Provider responsibility: Submit accurate, complete documentation to substantiate the coding of claims.
Modifier 25 use: Indicate a significant, separately identifiable E/M service by the same physician on the same day as a procedure or other service.
Denial and recovery: If documentation does not support the use of modifier 25, the claim may be denied and previously paid amounts recovered.
Appeals: Standard appeal rights apply for both prepayment and post-payment review outcomes.

Key Definitions

Definition of Modifier 25

DefinitionModifier 25 is a 2‑character code appended to an E/M CPT code to indicate a significant, separately identifiable evaluation and management service by the same provider on the same day as another procedure or service; must be supported by documentation.

PurposeUsed to report an E/M service when another service was provided to the patient by the same physician or qualified health care professional on the same day.

Documentation noteThe medical record must substantiate that the E/M service was above and beyond the usual preoperative and postoperative care associated with the other service.

Related modifiersModifier 57 is used for an E/M service resulting in a decision to perform surgery; modifier 59 covers significant, separately identifiable non‑E/M services.

Definition of CPT

Full nameCurrent Procedural Terminology (CPT)

Maintained byAmerican Medical Association (AMA)

PurposeProvides a standard language for coding and billing medical services and procedures.