Horizon Blue Cross Blue Shield of New Jersey will implement changes to our claim processing system to help ensure that claim payments are accurate and consistent with standard business practices.
Beginning August 1, 2014, our claim system will deny certain services (including Evaluation and Management (E&M) services) when performed by the same provider on the same day as another service/procedure even if one of the codes in question is appended with a Modifier 25.
Beginning August 1, 2014, our claim system will only recognize Modifier 25 when appropriately billed with a significant, separately identifiable E&M service performed by the same provider on the same day as another service/procedure, if the following criteria is met:
* The appropriate level of E&M service is billed.
* Modifier 25 is appended to the E&M service, which is above and beyond the other service or procedure provided, including usual preoperative and postoperative care associated with the procedure.
* The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly separate E&M service.
* The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevent separate reimbursement even if the E&M code is appended with a Modifier 25.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after August 1, 2014.
Click Here – A revised Modifier 25 Reimbursement policy is available online for your review.
References:
www.horizonblue.com
Horizon Blue Cross Blue Shield of New Jersey
