Anthem Updates Modifier 25 Policy Changes after Talks with AMA

As reported in the Dec. 28 edition of ACR@Work, Anthem Blue Cross recently announced plans to reduce reimbursement for evaluation and management (E/M) services when billed with modifier 25. At the AMA House of Delegates in November, the ACR joined with a number of other groups to support a resolution directing the AMA to advocate for appropriate reimbursement of both the procedure and E/M codes when billed with modifier 25.

As a result of this resolution, the AMA reached out to Anthem requesting that it halt plans to implement its modifier 25 payment reduction policy. The AMA also refuted Anthem’s expressed motivation for the policy by providing information clarifying how the recommendations of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) do not include duplicative physician work or practice expense for procedures typically billed with an E/M service on the same date.

Anthem responded to the AMA that it will still reduce payments for E/M services billed with modifier 25; however, that reduction will now be 25% instead of 50%, as originally planned. Additionally, the policy will now be effective March 1, 2018, for all states where it was previously announced—California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin. This new implementation date represents a delay for many of these states where the policy had been scheduled to go into effect in January or February. The policy will also be effective in Georgia and Virginia upon contract renewal.

Although the ACR agrees that these changes represent an improvement to the original Anthem policy, we join the AMA in continued opposition to this unjustified reduction of payment. The ACR has reached out to Anthem directly with our concerns and will continue to work with other specialty societies and the AMA to push back against this misguided policy.