Blue Cross Clarifies Modifier 25

Under Blue Cross Blue Shield of Michigan policy, evaluation and management services are not payable if they are given during a specified time period before and after the surgical procedure (global period). Reimbursement for certain evaluation and management services is reflected in the surgical fee.

Same-day evaluation and management codes reported with minor surgical procedures and a zero day postoperative period are payable separately for new and established patients as long as the services are reported with initial patient consultations. They are not payable for established patients, either office visits or follow-up consultations.

Modifier 25 is used to indicate a significant, separately identifiable evaluation and management service by the physician, on the same day of the procedure. The service is paid separately, but the modifier must be used according to CPT coding rules and supported by documentation in the medical record. Please refer to your national coding manuals for any limitations or instructions on the use of modifiers.

For additional clarification, contact your local Blue Cross Provider Consultant (below), or contact MSMS Reimbursement Advocate Stacie Saylor, at 517-336-5722 or ssaylor@msms.org.

Southeast and Mid-Michigan
Pam Yanis (313) 225-7880

Mid-Michigan
Jennifer Grennell (517) 322-4723

Southeast Michigan
Marion Dillard (313) 225-7778

West Michigan
(616) 285-2120