Evaluation and management (E/M) services billed with modifier 25

Notification number: 4416
Effective date: 1/1/2020
Notification date: 10/3/2019
Category: Modifiers

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.

Providers affected

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Plan type

  • Medicaid – Kentucky

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.