If you are a NY provider that accepts Fideliscare members then this blog post is for you!

E/M modifiers:

• Modifier 25 should be applied to E/M code
• If the member receives a same day procedure in addition to the E/M code please use the modifier 25
• If the patient receives a preventative service on the same day as E/M – please append modifier 25 on E/M code
• If on a same DOS the decision for a major surgery is made please use the modifier 57

What do you need to know!

• The E/M needs to represent a separate medical concern
• Medical necessity and work that is beyond the routine surgical global period or preventive exam.
• Claims will be clini locally reviewed to validate/confirm the E/M service

Reimbursement:

• 100% – reimbursement for the primary procedure
• 50%- for E/M service

Find this information useful? Follow my blog for more!

• Fideliscare: E/M reimbursement policy
• Oscar Health: member appeals info
• Aetna Betterhealth NJ: Mental Health PHP and transportation
• Molina Health newsletter claim reconsideration/appeal process
• Michigan Medicaid: Community health workers billing