Blue Cross recently completed two follow up studies on physician coding – one on evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier -25.

In September 2012, physicians who billed these codes at “considerably higher” frequencies for claims paid between May 1, 2011, and April 30, 2012, were notified of their individual results and informed that if subsequent analyses showed continued excessive usage, they may at a later date, be required to provide additional documentation to support the codes billed.

The recently completed follow up analyses looked at claims paid between October and December 2012. Blue Cross will soon be sending notices to physicians with the results of the analyses. One notice (47 for modifier -25 and 97 for E/M issues) indicates that the use of the codes or modifier has “notably decreased” since the last analysis. However, approximately 140 practices will receive notices indicating that the follow-up analysis indicates use of either the E/M codes or modifier -25 remains high and that EquiClaim, the company contracted to perform the studies, may contact them with a request for records.

Practices who receive a request for records from EquiClaim will have 14 days in which to comply. If after reviewing the records, EquiClaim identifies the documentation does not support the coding, they will pursue a refund request from the practice.

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

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.