An important billing consideration, specific to our FQHCs in Missouri, has been brought to our attention. This may also impact our CHC, Tribal, and Rural clients. Action may be required to enable proper billing.
According to federal coding guidelines, it is necessary to add a 25 modifier to the E&M code when another service is provided at the same encounter, including vaccine injections. NextGen Healthcare added functionality in NextGen KBM 8.3.10 that automatically adds the 25 modifier for these encounters.
In the state of Missouri, the Medicaid Injection Requirement specifies that RHCs and FQHCs may not bill separately for the administration of an injection regardless of whether or not there is an encounter with a core service provider. However, there are times when it would be appropriate to attach the 25 modifier to the E&M code.
Important Next Steps: We have collaborated with our internal KBM and billing resources to identify two possible workarounds:
Option #1 If the majority of your patients do not need the modifier, the functionality that adds the modifier to the template can be disabled and a claim edit added in Practice Management (PM) to add the modifier to those claims that allow and need it.
For option one, there are two ways to disable the template functionality. Either method should prevent the 25 modifier from being added to the E&M code for immunizations without affecting any other codes that should trigger the 25 modifier. The changes should be done in a Test or Development environment first and thoroughly tested before bringing the changes into Production.
Step-by-step instructions are available here: Modifier 25 Notice to Missouri Clients
Option #2 If the majority of your patients need the modifier, the template functionality could be left alone and a claim edit added to PM to remove the modifier on those claims that shouldn’t have it.
Our NextGen Healthcare Support Team is ready to help any client needing help to implement any of these changes. Please contact your assigned Account Manager with any questions.