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CMA continues advocacy on recent Anthem modifier 25 policy

June 24, 2019
Area(s) of Interest: Payor Issues and Reimbursement Commercial Payors 


The California Medical Association (CMA) along with the American Medical Association (AMA) and other state and specialty societies continue to voice concerns with the recent implementation of the Anthem Blue Cross policy denying certain evaluation and management (E/M) services submitted with modifier 25. The new Anthem 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 a response to a recent CMA letter regarding our concerns with the policy, Anthem reiterated the purpose of this initiative is to “avoid overpaying claims when modifier 25 is used inappropriately overriding claim edits intended to prevent duplicate payment for the E/M service.” At CMA’s request, Anthem clarified that it defines “recent” services as the billing of services occurring within an approximate two-month timeframe and defines a “same/similar” diagnosis as those within the same diagnosis family. 

Anthem had committed to reviewing examples of certain code combinations it should consider excluding from the edit. While we appreciate that commitment, CMA and other stakeholders remain concerned that there are numerous unidentified scenarios that would be subject to the edit, resulting in inappropriate denials for physicians.

CMA remains very concerned with the adverse impacts of this new policy upon our physician members and is continuing the dialogue with Anthem regarding our concerns.

The policy became effective March 1, 2019, for commercial claims, but was delayed until June 1 for its Medi-Cal line of business. Additionally, Anthem reports it has indefinitely delayed implementation date for Medicare Advantage claims, which was originally scheduled for May 1.

How Do I Know if My Claims Are Affected?

Anthem reports there is not one single denial reason code to identify claims denied due to the new modifier 25 policy, 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.

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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