Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99213-25 billed for date of servicer May 19, 2023. 
 
You asked the Plan to pay for code 99213-25. You say that ou billed code 99213 with the 25 modifier to show 
that the service was separate from the procedure. This service included a full body skin examination as well as 
discussing sun protection, regular skin examination in addition to identifying three suspicious lesions, two of 
which were biopsied, and one treated with cryotherapy. The Plan denied your request. The Plan says that the 
use of the 25 modifier to allow for separate payment of code 99213 is not supported by the medical record. The 
records do not show that a significant and separately identifiable E/M service unrelated to the decision to 
perform a minor surgical procedure was performed. 
 
The Plan follows Medicare rules. Medicare rules say that the 25 modifier may be appended to allow for 
separate payment of a code when the modifier is used to indicate a significant, separately identifiable 
evaluation and management (E/M) service by the same physician or other qualified health care professional on 
the same day of a procedure or other service. Modifier 25 indicates that on the day of a procedure, the patient's 
condition required a significant, separately identifiable E/M service, above and beyond the usual pre-and post-
operative care associated with the procedure or service performed. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 99213-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99213 is supported by the medical record. Our 
physician reviewer found you this reported procedure code with appended modifier 25 to indicate a significant, 
separately identifiable evaluation and management (E/M) service by the same physician on the same day of the 
procedure or other service, to bypass a National Correct Coding Initiative (NCCI) Edit with a procedure 
performed on same date of service. The documentation describes an established patient with a history of skin 
cancer.  The patient had no complaints.  During the examination, the physician found the patient to have 
abnormal areas on skin, which were treated.  In this case, modifier 25 would be supported, as the patient 
presented without known problems, however during examination abnormal areas were found.  The patient did 
not present to the office with known abnormal problems, and these were found upon examination by the 
treating physician.  Therefore, this procedure with appended modifier should be paid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99213-25 have been met. Therefore, we decided that the Plan has to pay 
for code 99213-25 billed for date of servicer May 19, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.