CurrentmhnPolicy CC.PP.013

Payment Policy: Clinical Validation of Modifier 25

Defines Centene's prepayment clinical review and reimbursement policy for Evaluation and Management (E/M) services billed with Modifier 25 and describes documentation, claims review, and appeal processes affecting providers submitting such claims.

Policy Summary

Payermhn

PolicyClinical Validation of Modifier 25

Policy CodePolicy CC.PP.013

Change TypeRoutine review - no material changes

Effective DateJan 1, 2023

Next Review DateNov 14, 2025

Key ActionProviders may submit medical records only when appealing a denial, not on initial claim submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prepayment reviewclaims flagged for clinical validation

denialoutcome when modifier use not supported

4 criteriaconditions that support reimbursement

AMA/CPT, CMS, OIGauthoritative guidance cited

Reimbursement Criteria for E/M with Modifier 25

Modifier 25 documentation and reimbursement criteria

Reimbursement for an E/M billed with Modifier 25 is recommended when documentation supports a significant, separately identifiable E/M service. If documentation does not indicate a separately identifiable service, the primary procedure will be reimbursed and the E/M billed with modifier 25 will be denied.

Documentation must satisfy the criteria for the E/M service reported; claim history/diagnosis codes should indicate the separately identifiable service

ONE of the following must be met

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
Patient’s condition is worsening as evidenced by diagnostic procedures being performed on the date of service

Policy Summary

Payermhn

PolicyClinical Validation of Modifier 25

Policy CodePolicy CC.PP.013

Change TypeRoutine review - no material changes

Effective DateJan 1, 2023

Next Review DateNov 14, 2025

Key ActionProviders may submit medical records only when appealing a denial, not on initial claim submission.

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.

Modifier and Procedure Coding Guidance

ModifierModifier

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 minor surgical procedure guidance — global period 000/010

Policy summaryPer NCCI, procedures with global period 000 or 010 are defined as minor surgical procedures and the decision to perform them is included in the procedure value; therefore E/M related to these procedures is generally not reportable separately.

Exception for unrelated E/MA significant, separately identifiable E/M service that is unrelated to the minor procedure may be reported separately with Modifier 25.

New patient statusBeing a new patient alone is not sufficient to justify reporting a separately identifiable E/M on the same date as a minor surgical procedure.

ExamplesNCCI notes osteopathic manipulative therapy and chiropractic manipulative therapy have global periods of 000 and are considered minor surgical procedures.

Edits and processingNCCI contains edits based on these principles and A/B MACs may apply separate practitioner service edits.

Claims Review, Documentation, and Appeals

Prior Authorization

Prepayment clinical validation and appeal submission guidance

Code auditing software flags all claims billed with modifier 25 for prepayment clinical validation; after validation a claim is either released for payment or denied for incorrect modifier use. Providers should not submit medical records with the initial claim; if the claim is denied for insufficient documentation, the provider may submit an appeal/reconsideration with all pertinent medical records for the date of service and procedures billed per the provider manual.

Do not include medical records with the initial claim — initial review considers only the claim and member/provider history.
If denied for insufficient documentation, submit an appeal/reconsideration following provider manual guidelines and include all pertinent medical records for the date of service and procedures billed.

Key Definitions

Definition of Modifier 25

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

Required relationship to other serviceThe E/M must be above and beyond the services associated with the procedure or beyond the usual pre- and postoperative care for the procedure.

Authoritative sourcesCentene uses AMA/CPT and CMS guidance; CPT, CMS, and OIG specify the meaning and appropriate use of Modifier 25.

Claim review practiceCentene performs prepayment clinical claim review on all services billed with Modifier 25 to determine appropriate use.

Minor surgical procedure global period guidance

Minor procedure global periodsProcedures with global period 000 or 010 are considered minor surgical procedures and their decision to perform is included in the procedure value.

Separate E/M reporting standardA separately reported E/M on the same day is generally not supported for minor procedures unless the E/M is significant and unrelated to the procedure — reportable with Modifier 25.

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

Applicability to new patientsThese guidelines apply to new patients; 'new' status alone does not justify reporting an E/M with a minor procedure.