ADVICE – Proper use of billing modifiers 25 and 59
| To: | Health Plan of San Joaquin (HPSJ) PCPs, Providers and Practice Billing Managers |
| From: | Provider Services Department |
| Subject: | ADVICE – Proper use of billing modifiers 25 and 59 |
| Business: | Medi-Cal, AIM (now known as Medi-Cal Access Program) |
To advise providers on the proper use of modifiers 25 and 59 – and to decrease the amount
of overpayments to providers when billing these modifiers inappropriately, and thus
reducing post-payment reimbursements from network practices to HPSJ – the following
guidance is offered:
Modifier 25 is to be used with an E&M (office visit) when it may be considered global to
another procedure billed on the same day, and when management was performed above
and beyond the service or procedure on the same date.
ATTENTION PCPs:
When the new member’s initial visit is for a sick visit, and a Wellness Exam has not yet taken place, this visit is an opportunity to at least start the Wellness Exam. This session may be billed as a new member Wellness Exam, using modifier 25 in conjunction with the sick visit.
Modifier 59 is to be used when a provider feels the procedure being performed should be
unbundled and additional payment rendered. Modifier 59 should ONLY be used when a more appropriate modifier is not available.
NOTE: While documentation may not always be requested with the submission of
claims using such modifiers, it would need to be available upon request by HPSJ.
If you have any further questions, please contact our Provider Services Department at
(209) 942-6340.