Anthem Announces Plan to Fully Rescind Modifier 25 Payment Cuts

Anthem Blue Cross Blue Shield announced that the company plans to halt an existing policy that reduces payments when physicians bill an evaluation and management (E/M) service appended with payment modifier 25 and a minor surgical procedure performed on the same day. The policy change, originally slated to begin March 1, has not yet gone into effect.

Payment modifier 25 is a Current Procedural Terminology code that creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service.

In recent communications (PDF) with the American Medical Association (AMA), Craig E. Samitt, MD, MBA, executive vice president and chief clinical officer of Anthem, Inc. stated, "While Anthem is confident that duplication of payment for fixed/indirect practice expenses exists when physicians bill an E/M service appended with modifier 25 along with a minor surgical procedure (0 or 10 day global) performed on the same day, the company believes making a meaningful impact on rising health care costs requires a different dialogue and engagement between payers and providers."

Anthem's decision is due in part to extensive discussion between the payer and various stakeholders, including the ACC, AMA and the other specialty societies. As part of this discussion, the ACC and others have expressed serious concerns about the policy. Unfortunately, there is some concern that other payers may be considering or actively implementing similar modifier 25 payment reductions. ACC advocacy staff encourage members that experience reduced payments as a result of such policies to contact the College with information on those insurers.

Anthem will send formal notification of the anticipated policy change to its contracted providers in the coming weeks. Members should carefully review their Anthem claims to ensure no adjustments were incorrectly made.

Keywords: ACC Advocacy, Blue Cross Blue Shield Insurance Plans, American Medical Association, Insurance Carriers, Current Procedural Terminology, Surgical Procedures, Minor, Health Expenditures, Health Care Costs, Physicians, Medicine

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