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CMA continues to challenge Anthem modifier 25 policy

May 14, 2019
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 


The American Medical Association (AMA) and other state and specialty societies have now joined the California Medical Association (CMA) to push back on a new Anthem Blue Cross policy that will deny certain evaluation and management (E/M) services submitted with modifier 25. 

CMA is very concerned with the adverse impacts of this new policy upon our physician members and has been in continued dialogue with Anthem regarding our concerns. The new policy 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).

In May, CMA sent a letter to Anthem Blue Cross expressing continued concerns over implementation of the policy, which is aimed at addressing inappropriate use of modifier 25. The letter, which follows a recent meeting with Anthem representatives, highlights significant concerns with Anthem’s policy. The policy became effective March 1, 2019, for commercial claims; April 1, 2019, for its Medi-Cal line of business; and May 1, 2019, for Medicare Advantage claims.

According to Anthem, there is not one single disposition code for the new modifier 25 denials, because it is dependent on how the code has been billed. Some examples that physicians may see include, but are not limited to:

  • This service is denied because it is considered to be part of another service already performed and reimbursed.  
  • The service is denied because the service billed is not covered separately and is considered part of the member's primary procedure. Participating providers are prohibited by contract from balance billing the member for this charge.  
  • Service is denied because it is incidental based on the National Correct Coding Initiative as published/maintained by CMS. Participating providers are prohibited by contract from balance billing the member for this charge.

CMA appreciates Anthem’s commitment to look at examples of certain codes it should exclude from the edit. However, CMA and other stakeholders remain concerned there are numerous unidentified scenarios that would be subject to the edit, resulting in a significant number of inappropriate denials for physicians.

If you believe you have been impacted by these denials when your medical records support payment of the unrelated, significant and separately identifiable E/M service, CMA wants to hear from you. Contact CMA’s Center for Economic Services at (888) 401-5911 or email us.

 

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