Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Anthem Reduces Payment for Same Day Services

Anthem Reduces Payment for Same Day Services

On March 1, 2018, Anthem Blue Cross Blue Shield will begin reducing payment by 25 percent for Evaluation and Management (E&M) Services performed on the same day as a minor surgery in Indiana, Kentucky, Missouri, Ohio, Wisconsin, and several other states across the country.

According to Anthem, the policy affects E&M services billed with CPT codes 99201-99215 and modifier -25 when performed on the same day as minor surgeries that are billed with CPT codes 10000-69999 (excluding CPT 36415, 36416, and 69210). E&M services performed in the Emergency Department, which are billed with CPT codes 99281-99285, are not affected.

A Minor Reprieve

Originally, Anthem was prepared to reduce payment for the affected E&M services by 50 percent, but later changed the payment reduction to 25 percent. According to the American Medical Association, the change followed a meeting between representatives from their organization and senior Anthem leaders which took place in late 2017. The AMA met with Anthem hoping to dissuade the payer from reducing the payments at all.

“The AMA provided information clarifying how the recommendations of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) do not include duplicative physician work or practice expense for procedures typically billed with an E&M service on the same date,” the AMA reported in their December 28, 2017, Advocacy Update. “The AMA also provided Anthem with further supportive data on those procedures for which practice expense already has been reviewed by the RUC and, using Medicare payment data, shared many procedure codes for which implementation of the proposed policy would result in steep physician payment cuts after accounting for direct expenses.”

Separately Identifiable

In fact, the use of modifier -25 is limited to instances when the E&M code is separately identifiable from the procedure being performed. According to WPS-GHA, Indiana’s Medicare Administrative Contractor, if the work performed is “consistent with that normally performed with the procedure,” then the modifier should not be used. WPS-GHA lists the following guidelines for the appropriate use of modifier -25:

  • 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.
  • Use Modifier 25 with the appropriate level of E/M service.
  • The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010, or 090 days.
  • An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
  • Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.

Provider Response

This new policy by Anthem is one of several recent changes that have upset the provider community. Anthem also has begun to deny payment for emergency department visits they deem “non emergencies” and to deny payment for advanced imaging services like CT scans and MRIs in the outpatient hospital setting. In a January 16, 2018, letter to Anthem, 11 medical associations asked the payer to discontinue or cancel these policies.

“We urge Anthem to rescind these policies and consider engaging the provider community in a concerted, serious dialogue on how to best deliver medical care in a cost effective and efficient manner,” the physician groups wrote. “Failure to rescind these policies could jeopardize patient care and, furthermore, these new policies could serve to undermine a relationship between Anthem and a broad array of the physicians who treat your beneficiaries.”

Among the signatories were the American College of Emergency Physicians, the American College of Radiology, the American College of Surgeons, and the American Society for Radiation Oncology.

For more information about the Anthem Policy, review Anthem’s January 10, 2018, Network eUpdate.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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