02/13/2020

32BJ-Payments for E&M codes with Modifier 25 Once Every 60 Days

According to 32Bj which is a self funded policy. They will only pay for an EM code with modifier 25 only once evry 60 days, even if substantially different diagnosis is billed with a surgical code(s) -59 modifier with a 0, 10,90 day global. If the substantially different diagnosis is billed more than once in this 60 day EM -25 interval it will be included. This is 32BJ policy. They will not reference me an LCD or policy #. I did contact my representative requesting a copy of this policy. It seems you will need a 79 modifier.

Unfortunately, the information is not published by Local 32BJ or by their healthcare administrator, Empire BC/BS. These guidelines outlined are not in any public member materials for union members, such as a benefit booklet or the summary of benefits. The information may be only for certain parties, such as provider representatives and customer service. Because the information is not published, going to provider relations with examples of denials would be the best route to verify the validity of global denials from the payer.