Anthem Blue Cross to deny certain E&M services billed with modifier 25

March 13, 2019
Area(s) of Interest: Practice Management Payor Issues and Reimbursement Commercial Payors 

Anthem Blue Cross recently announced that it will begin denying certain evaluation and management (E&M) services submitted with a modifier 25. 

Modifier 25 allows separate payment for a significant, separately identifiable E&M service provided on the same day as a minor procedure or other reported health care service. 

For commercial claims processed on or after March 1, 2019, Anthem will deny an E&M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record for the same provider (or a provider with the same specialty within the same group TIN).  This policy will also apply to its Medi-Cal line of business beginning with claims processed on or after April 1, 2019.

According to Anthem, it is implementing the change in policy because providers often bill a duplicate E&M service on the same day as the procedure even when the same provider or provider in same specialty within same group recently billed a service/procedure which included an E&M for the same/similar diagnosis. Anthem states that the use of modifier 25 to support separate payment of the E&M service is not consistent with correct coding or Anthem’s policy on use of modifier 25.

The California Medical Association has reached out to Anthem to discuss the potential impact of this new policy on our physician members. 

The notice advises providers who believe their medical records support payment of the unrelated, significant and separately identifiable E&M service to submit an appeal, including medical records, through Anthem’s Provider Dispute Resolution process for Commercial or Medi-Cal plans.


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