Humana has informed us that they will only pay an E/M with modifier 25 if the problem was significant enough to require a prescription, lab order, surgery recommendation, or something like that. If it only requires counseling or OTC medication, it is not "significant" enough to bill a separate E/M.

Example: Pt came in for evaluation of a rash, and the provider examined the area and recommended an OTC cream. The provider happened to notice an unrelated suspicious lesion and performed a biopsy. So we billed 11100 for the lesion and 99212-25 for the rash. Humana denied the 99212-25 stating that the rash was not a "significant" enough problem to bill separately because the recommendation was only for OTC medication.

Is this appropriate?