Expect changes regarding certain evaluation and management codes for reimbursement.
Effective Aug. 1, Horizon will change how we consider certain evaluation and management (E&M) codes included on professional claims for reimbursement.
Currently, when an E&M service appended with Modifier 25 is submitted for the same date of service as another procedure code (or codes) representing services that have a global surgical period of 0, 10, or 90 days, Horizon’s claim processing system considers the E&M service at 100 percent of the appropriate Horizon allowance.
Beginning on Aug. 1, however, there will be significant cuts to reimbursement for physicians in these scenarios. Horizon Blue Cross of New Jersey and its affiliates under their Medicare Advantage plans, Braven Health, and New Jersey state plans, will consider E&M services appended with Modifier 25 at 50 percent of the appropriate Horizon allowance (or at the provider’s submitted charges, if less) if one or more procedure codes that have a global surgical period of 0, 10, or 90 days are included on the same claim (or on another claim for that same date of service).
In late May, Cigna announced that it will begin requiring the submission of medical records with all E&M claims with CPT codes 99212-99215 and Modifier 25 when a minor procedure is billed.
Modifier 25 allows separate payment for a significant, separately identifiable E&M service provided on the same day as a minor procedure or other reported healthcare service. The updated Cigna policy will become effective nationwide on Aug. 13.
Failure to submit the required medical records will result in a denial.
Programming Note: Listen to Terry Fletcher’s live report on this developing story today during Talk Ten Tuesdays at 10 Eastern.
As healthcare continues to evolve in response to technological innovation and changing patient expectations, coding professionals are at the forefront of documenting that transformation. The
Continuing our look at areas where we see confusion we will examine the assignment of the long term use codes for anticoagulants versus antithrombotics/antiplatelets. GoodRx.com,
Please log in to your account to comment on this article.
Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals. Don’t miss this chance to protect your hospital’s revenue and reputation!
Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!
Uncover critical guidance. HIM coding expert, Kay Piper, RHIA, CDIP, CCS, provides an interactive review on important information in each of the AHA’s 2025 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s fourth quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.
Fraud convictions don’t just punish a few bad claims; they can wipe out years of reimbursements. Don’t wait for an audit to learn the rules. Join Frank Cohen, MPA, for a live Q&A on spotting red flags, avoiding liability, and protecting your practice. Register now and bring your questions!
Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025. Register today and be a part of the conversation!
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Notifications
