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AAO-HNS Comments on Emblem Health’s Modifier 25 and E/M Policy (4/11/19)

AAO-HNS Comments on Emblem Health’s Modifier 25 and E/M Policy (4/11/19)

On April 3, the Academy submitted a comment letter to Emblem Health opposing the company’s reimbursement policy to deny E/M services billed with modifier 25 within 28 days of a previous face-to-face service. The following will be denied:

  • The E/M service (92002-92004, 92012-92014, 99201-99380, 99441-99499) is billed with modifier 25 on the same day as a procedure with a 0-day, 10-day, or 90-day postoperative period.
  • The patient has had a face-to-face service with the same provider for the same condition as the E/M service, and the 0-day, 10-day or 90-day procedure within the previous 28 days.

The comment letter included a thorough CPT code analysis detailing the impact of this misguided policy on procedures commonly billed by the specialty. To read the Emblem Health policy, visit https://www.emblemhealth.com/Providers/Claims-Corner/Coding/Modifier-25-with-Evaluation-and-Management-Services-Reported-with-Procedures.

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