Audits, Modifiers and Clinical Guideline Reviews

Horizon BC/BS

Horizon BC/BS continues to audit many providers (mostly in New Jersey) when billing certain CPT codes with specific modifiers such as 25 and 59.

Modifier 25: A significant, separately identifiable E/M service. It may be necessary to indicate that on the day a procedure identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M services to be reported.

The E/M service may be prompted by the symptom or condition for which the procedure was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. This is reported by adding modifier 25 to the appropriate level of E/M service. Example: 99213-25.

Modifier 59: A distinct procedural service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

Documentation must support a different session, different procedure, different site or separate injury not ordinarily encountered or performed on the same day by the same individual.

However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non E/M service performed on the same date, use modifier 25. Example: 97140-59, Medicare: 97140-59-GP-GY.

Contact us for a free 15 minute consultation – it could save you thousands of dollars. Also, speak to us about our Coding & Compliance Manuals…just in case an unhappy patient, jealous competitor or disgruntled employee files a complaint against you.


In New York & Pennsylvania Aetna will now require pre-certification reviews for chiropractic services when rendered on an outpatient basis. National Imaging Associates (NIA) will be oversee this new utilization management program. Their services are intended to ensure that chiropractic and physical medicine services are delivered with consistent nationally recognized clinical guidelines.

We have reviewed their clinical guidelines, checklists and other tools specific to chiropractic and physical medicine services. For some providers this program started already and for others it begins January 1, 2019. Do not submit any pre-certification requests to Aetna. Contact us for assistance.

For more info, please contact Dr. John Pecora @

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