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

Anthem Tweaks Modifier 25 Policies

Anthem Tweaks Modifier 25 Policies

Anthem is once again tweaking policies for modifier 25, apparently still trying to get a handle on separately billed evaluation and management (E/M) services that are provided on the same day as a minor surgery.

Last year, Anthem threatened to reduce payment for what are known as “significant, separately identifiable” E/Ms by 50 percent. Amid public outcry, they then backed off a little, promising just a 25 percent reduction before eventually scrapping the plan altogether just days before the policy was to take effect.

Now, Anthem is trying again to minimize what it calls the “duplication of payment for fixed/indirect practice expenses when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day.”

Denials for Similar “Recent” Visits

First, beginning March 1, 2019, Anthem may deny an E/M service with a modifier 25 billed on the same day as a related minor procedure if another service or procedure for the same or similar diagnosis was “recently” billed. No definition of “recent” was provided in the policy announcement.

“Anthem Blue Cross and Blue Shield has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis,” the payer explains. “The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25.”

No E/M with a Major Surgery

Next, Anthem released a modifier 25 policy update for their Indiana Medicaid lines that says effective April 1, 2019, Anthem will not allow separate reimbursement for E/Ms performed on the same day as a major surgery (90-day global period). Anthem does still allow separate reimbursement for an E/M visit provided on the day prior to or the day of a major surgery when it’s billed with Modifier 57, however, which indicates the E/M visit resulted in the initial decision to perform the major surgical procedure.

Post-Service Reviews

Finally, for the past year (beginning in the first quarter of 2018) Anthem has began conducting post-service reviews of professional claims billed with the 25 modifier, among others, as well as E/M services billed during a global surgery period. According to Anthem, providers may be required to submit additional documentation related to those services, as well cough up recoupments if “billing discrepancies are identified.”

Interestingly, Anthem did proceed with plans to reduce reimbursement for E/M services billed with modifier 25 in one instance: when a same day E/M is billed with a preventive exam visit. According to Anthem Policy 0026, which went into February 1, 2018, “when during the course of performing a preventive examination, an abnormality or preexisting problem is encountered or a concern is voiced by the patient which requires significant additional work to be performed by the provider,” both the preventive medical exam and a problem-oriented E/M service may be reimbursed.

However, the maximum allowed for the E/M will be reduced by 50 percent, since “there is duplication of the indirect practice expense (i.e.  scheduling the visits, staffing, obtaining vital signs, lighting, and supplying the examination room) when performing both the preventive/wellness exam and the problem oriented E/M during the same encounter.” Which sounds a lot like the reason they used last year for the payment reduction policy they ultimately scrapped.

As Anthem continues to tweak policies and audit claims around this issue, could the payer be headed for another attempt to reduce payment for all E/M services billed with modifier 25? Only time will tell.

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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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