What is changing
We limit reimbursement of charges for E/M services appended with modifier 25 to one per date of service for a given provider.
Modifier 25 is defined as "Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service."
Why is Humana implementing this change
According to the AMA CPT manual, modifier 25 is used to report a separately identifiable E/M service performed on the same date of service. It is inappropriate to report services with this modifier more than once on a given date.
- Inpatient/Outpatient Facilities
- Physician/Health Care Providers
- Medicaid – Kentucky
Disclaimer: Claim edits do not supersede the necessity to obtain preauthorization. Preauthorization requirements still apply. Modifiers should be used when appropriate to accurately represent the services rendered. Please note that this notification may not describe previously implemented rules that still apply; the intent is to give notice of an upcoming change.
If requested by the self-funded group, all code-editing rules posted on Humana.com/edits for fully insured commercial Humana members also may be applied to self-funded members.
Submit code edit questions online
Physicians and healthcare providers can submit specific questions about code editing on the multipayer Availity Provider Portal. Humana's Code Editing Questions tool is located under Claims, Research Procedure Code Edits.