Clover Health Modifier 25 Reimbursement Policy Policy # RP-060
Policy Title
Modifier 25 Reimbursement Policy
Policy Department
Payment Strategy and Operations
Effective Date
4/1/2022
Revision Date(s)
Next Review Date
Disclaimer:
Clover Health applies CMS criteria and guidelines, National Coverage Determinations (NCD), Local Coverage
Determinations (LCD), Clover Policies, and MCG for determining medical necessity. Clover Policies are intended to
provide a standard guideline but are not used to preempt providers' judgment in rendering services. Providers are
expected to provide care based on best practices and use their medical judgment for appropriate care.
Description:
Modifier 25 is used to indicate that a significant, separately identifiable evaluation and
management (E/M) service was performed above and beyond the procedural code
provided on the same day.
Definitions:
● Same physician - Physicians in the same group practice who are of the same specialty
are considered to be the same. In this instance they must bill and be paid as though
they were a single physician.
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Clover Health Modifier 25 Reimbursement Policy Policy # RP-060
Policy:
This policy addresses how Clover Health applies the Medicare guidelines for E/M services
appended with the modifier 25 and are considered for reimbursement.
● Modifier 25 is used to identify a separate and significant identifiable Evaluation and
Management (E/M) service when performed by the same physician or other qualified
healthcare professional on the same day of a procedure or other service.
● This means that on a day a service or procedure is performed, the patient’s condition
may need a separate, significant identifiable E/M service above and beyond the
service which was already provided or beyond the usual pre/postoperative care that
was associated with the procedure performed.
● The submission of modifier 25 appended to an E&M code indicates that
documentation is available in the patient's records that will support the significant and
separately identifiable nature of the E&M service.
Correct use of modifier 25
● Appended to an appropriate level of E/M service.
● If an E/M service may occur on the same day as a procedure. Clover allows payment
when the documentation supports the 25 modifier.
● When the procedure performed has a global period listed on the Medicare fee
schedule relative value file.
Incorrect use of modifier 25
● When modifier 25 is used by a physician other than the physician performing the
procedure.
● Documentation shows the amount of work performed is consistent with the level of
effort normally performed and is not a significant, separately identifiable E/M service.
● Modifier 25 should not be reported on procedure code 99211.
● Do not append the following E/M codes that are clearly for new patient only:
○ 92002
○ 92004
○ 99202-99205
○ 99341-99345
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