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Claims with Modifier 25 Erroneously Denied with RAD Code 0090

January 18, 2019

The Department of Health Care Services (DHCS) has identified a claims processing issue causing claims with CPT codes within the range of 99200 – 99999 to be erroneously denied with Remittance Advice Details (RAD) Code 0090: The combination of procedure code and modifier is not valid on the dates of service billed when billed with modifier 25 (significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service). The issue affects claims submitted on or after December 22, 2018, until January 16, 2019.

No action is required of providers. DHCS and the California MMIS Fiscal Intermediary are working to resolve this issue. Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates regarding this issue.