BCBSIL – 25 Modifier Letter

BCBSIL -25 MODIFIER LETTER

Editor’s Note: This information came out prior to the 2017-2019 “claims edit process” problems with the -25 modifier. Although this information contained in this article is accurate, informative, and still correct, it is not a cure for the “claims edit process” problems the profession is facing currently.

A number of chiropractic physicians in Illinois recently received a letter from BlueCross BlueShield of Illinois regarding the use of Modifier 25.  Although the exact purpose of the letter was not clearly stated, the letter was sent from BCBSIL’s Special Investigations Department, stating that the practice in question utilized “Modifier 25 with over ninety percent (90%) of established patient Evaluation & Management (E/M) services.” 

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Additionally, the letter mentioned that BCBSIL “may request medical records for a more thorough review and take additional action including, but not limited to, issuing a refund request as a result of overpayments based on the incorrect coding of services billed.”  Unsurprisingly, this letter was sent to a large number of chiropractic physicians.

Following Standard of Care

First, the Illinois Chiropractic Society is working to clarify the intent of the letter through our liaison relationships at BCBSIL.  The ICS has concerns about the content of the message.  We believe our members, in most cases, are following the standard of care that mandates initial exams and periodic re-exams (E/M) services.  In following that standard of care, these physicians are required to use the -25 modifier when such E/M services are performed on the same date as chiropractic manipulative therapy.  Our liaisons will be meeting with BCBSIL this week to discuss the overall meaning of the letter, as well as our concerns about it.

Second, nowhere within the letter does BCBSIL indicate that you should not use the -25 modifier.  Additionally, it does not say that you are being audited.  Instead, the letter merely indicates that your practice has utilized Modifier -25 with over ninety percent of your established patient E/M services.  However, the very nature of our treatment protocols and proper billing practices require that these E/M services are performed and the -25 modifier used.  We are attempting to inform BCBSIL regarding these protocols and standard of care.

Third, the ICS would like to offer its members the following general clarification  regarding exams and modifier -25:

1)      [According to CPT Coding Guidelines] The -25 modifier is “necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual… care associated with the procedure that was performed.” Thus, the E/M service must be above and beyond what is required under the service being performed.  For chiropractic physicians, the -25 modifier will be used in conjunction with a CMT (9894x) where the examination is significantly greater than the professional component inherent within the CMT CPT.

2)      Equally as important, the significantly greater E/M service must be substantiated within the documentation to warrant the use of the -25 modifier.  As we indicate to our members regularly, documentation is critical.

3)      The level of E/M code billed must also be substantiated within the documentation. 

4)      The E/M must be necessary according to standards of care.  Doctors will not be able to substantiate the necessity of a significant, separate E/M service for every adjustment visit by a patient. 

For further information regarding when re-examinations should occur within a treatment plan, please review the following articles:

The following articles cover billing insurance the correct evaluation and management CPT code:

As a reminder, the Illinois Chiropractic Society is in contact with BCBSIL regarding this and many other issues.  If we are able to obtain additional information regarding BCBSIL’s position regarding the use of the -25 modifier, we will inform our members immediately.

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ICS Staff

The Illinois Chiropractic Society staff works collaboratively on many topics to bring the most comprehensive and relevant information to our members. We have over 60 years of chiropractic experience and understand the heartbeat of the profession. We all look forward to providing relevant information to our members for years to come.

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