Payer advocacy

Skin, hair, and nail issues are often obvious to patients because they are visible, and patients typically present with multiple concerns due to their ability to see changes. Dermatologists frequently use modifier 25 to bill for both an evaluation and management or E/M service and an unrelated procedure in the same visit. Unfortunately, some payers give modifier 25 claims higher scrutiny, and others have tried to set policies that narrow its use.

The Academy believes separate services should be reimbursed appropriately and in accordance with established coding conventions and guidelines.

However, payers have implemented or considered policies that automatically reduce reimbursement of claims based on modifier 25 reporting. The Academy opposes reimbursement policies implemented by insurance companies that reduce payment when modifier 25 is appropriately documented.

The Academy asserts that modifier 25 is an important documentation tool to allow physicians to appropriately code for visits that can frequently be complex and multifaceted. We have opposed numerous proposed policy edits that would create unnecessary barriers to efficient care and result in unwarranted claims denials, which contribute to the growing administrative burdens impacting practices across the country.

Notable payer advocacy updates

• Aetna: The AADA is currently addressing concerns with reported increase in denials and supporting documentation.

• CIGNA: Cigna indefinitely delayed modifier 25 policy after the AADA successfully pushed for the delay that would have required submission of office notes for each claim reporting and E/M with a minor procedure.

• UnitedHealthcare (UHC): The AADA is continues to address concerns with UHC “Smart” edit program.

State payer advocacy

• Horizon BCBS: The AADA worked with the Dermatological Society of New Jersey to address troublesome -25 modifier policy.

• BCBS Massachusetts: The AADA worked with the Massachusetts Academy of Dermatology to submit proposed legislation that would restrict payers from implementing modifier 25 payment reductions.

  • See the Massachusetts proposed Modifier 25 Legislation (PDF) that other state dermatology societies may use as a model for their own state legislation.

  • Avery LaChance, MD, FAAD, (MA) provides an overview on Modifier 25 legislation as a guide for other states.

Academy resources

The AAD has resources to guide dermatology practices in appropriate documentation and coding and effectively appeal inappropriate modifier 25 denials. If you have coding questions, please submit to coding@aad.org. Contact privatepayer@aad.org to report payer issues or if you have questions.

• Modifier 25 coding

• Modifier 25 educational tool (PDF)

• Successful documentation tips

• Private payer appeal letter tool