Blue Cross recently conducted two studies of physician coding, one on new and established evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier -25. The analyses involve claims paid by Blue Cross between May 1, 2011 and April 30, 2012.

Physicians who, according to the insurer, billed these codes at "considerably higher" frequencies, are receiving letters that contain their individual results. The letters – sent by EquiClaim, the company contracted to perform the studies – advise physicians that their use of these high-level codes is greater than others in their specialty and warns that their usage will continue to be monitored. The notices also include information about Blue Cross's relevant billing policies.

Blue Cross advises that approximately 5,000 notices total will be sent to physicians (1,826 for modifier 25 issues and 3,216 for E/M issues). The notices are not audit letters and do not ask for medical records at this time. They do, however, state that if subsequent analyses continue to show excessive usage, EquiClaim may request medical records and, if appropriate, request refunds if the documentation does not support the coding.

Physicians who wish to dispute the Blue Cross findings may do so in writing by submitting an appeal to Anthem Blue Cross c/o EquiClaim, P.O. Box 5037, Naperville, IL 60567-5037.

EquiClaim will also be performing studies on physician usage of modifiers -24, -57 and -59 at a later date.

While Blue Cross first announced its CPT coding compliance program in November 2011, they have, at the California Medical Association's (CMA) urging, modified the program significantly. Although the insurer had originally planned to audit all modifiers at the same time, it has agreed to stagger the studies. Blue Cross has also agreed to modify the program to first provide education on usage and coding criteria, rather than a punitive and administratively burdensome audit as originally intended.

CMA appreciates Blue Cross’s willingness to approach the issue from an educational perspective rather than fostering the perceived impression that physicians are intentionally doing something wrong.

Questions about the analyses can be directed to EquiClaim at (866) 481-1479 (select option 4).

Questions: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmadocs.org.