Effective Date: October 1, 2020

Purpose:
Provide guidelines for the recognition of modifier -25 when appropriately appended to problem-oriented Evaluation and Management (E/M) services for participating and nonparticipating providers when billed in conjunction with a preventive medicine service and reimbursement guidelines for counseling billed with preventive services.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
• Preventive Medicine Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Policy:
Preventive medicine services (CPT codes 99381-99387, 99391-99397) are comprehensive in nature and reflect a gender and age appropriate history and examination which include counseling or anticipatory guidance, and risk factor reduction intervention. Preventive medicine services are usually separate from disease-related conditions. On occasion, a pre-existing problem or an abnormality is addressed during the preventive/well visit, and independently significant elements of problem-oriented E/M services are provided during the preventive visit.

When problem-oriented Evaluation and Management (E/M) services (Procedure codes 99201-99201, 99211-99215, G0463) are rendered during a well visit, Horizon NJ Health will reimburse the preventive medicine service at 100% and the problem-oriented Evaluation and Management (E/M) service code that is appended with modifier -25 at 50% of allowable charges. If the problem-oriented Evaluation and Management (E/M) service is minor and is not properly documented, or if the code is not submitted with modifier -25 appended, it will not be reimbursed.

Horizon NJ Health’s reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the significant, separately identifiable problem-oriented Evaluation and Management (E&M) service performed by the same provider on the same day of the original service or procedure based on the above criteria.

This policy recognizes that the services below, performed on the same day by the same provider are performed once, rather than twice:

• Scheduling of the patient.
• Taking and documenting the patient’s history.
• Taking and documenting the patient’s vital signs.
• Use of the examination room.
• Generation and or mailing of the bill and collection of the requisite copay/coinsurance, etc.

In addition, pursuant to the AMA’s CPT code guidelines, preventive counseling (CPT codes 99401-99412), is an included component within a preventive medicine visit. Therefore, preventive counseling is not separately reimbursed when billed by the same provider during the same session as a preventive medicine visit.

Note: Same provider is defined by Horizon NJ Health as a physician and/or other health care professional of the same group and same specialty physician or other health care professional reporting the same Federal Tax Identification number

Procedure:
Horizon NJ Health shall recognize and consider for reimbursement a significant, separately identifiable problem-oriented Evaluation and Management (E&M) service appropriately appended with modifier -25 when performed by the same provider on the same day of a preventive medicine visit. The separate problem-oriented Evaluation and Management (E&M) service shall reimburse at 50% of the applicable Horizon NJ Health fee schedule amount. The preventive medicine visit shall be reimbursed at 100% of the Horizon NJ Health fee schedule.

Horizon NJ Health shall deny preventive medicine counseling (CPT codes 99401-99412) when billed during the same session as a preventative medicine visit (CPT codes 99381-99387, 99391-99397).

Resources:
Claims Processing Manual: Chapter 18 - Preventive and Screening Services
cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.