Anthem to Reduce E/M Reimbursement When Billed with Modifier 25

Anthem Blue Cross recently announced changes to its reimbursement policies for modifier 25. As of Jan. 1, 2018, Anthem plans in California, Connecticut, Kentucky, Maine, Nevada, New Hampshire, Ohio and Wisconsin will reduce reimbursement for evaluation and management (E/M) services by 50% when billed with modifier 25. This policy will expand to Missouri on Feb. 1, and Colorado, Indiana and New York on March 1. Similar policies were enacted by Tufts Health Plan in 2014, Blue Cross & Blue Shield of Rhode Island in 2016, and Independence Blue Cross earlier this fall.

The ACR strongly opposes these changes and believes that providers should be reimbursed appropriately and in accordance with the Current Procedural Terminology coding guidelines when performing significant, separately identifiable and medically necessary E/M services on the same day as a procedure.

The ACR is currently engaged in direct outreach to payers and is also partnering with a coalition of other specialty societies to push back against these policies. At the AMA House of Delegates meeting in November, the ACR joined with a number of other organizations to support a resolution directing AMA to advocate to ensure that when an E/M code is appropriately reported with a modifier 25, that both the procedure and E/M codes are paid at the non-reduced, allowable payment rate.

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