The California Medical Association (CMA) recently met with Anthem Blue Cross to express concerns over its recently announced policy aimed at addressing inappropriate use of modifier -25.

Modifier 25 allows separate payment for a significant, separately identifiable E&M service provided on the same day as a minor procedure or other reported health care service. 

Per the new policy, Anthem 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). The policy took effect March 1, 2019, for commercial claims, and April 1, 2019, for its Medi-Cal line of business. It will also apply to Medicare Advantage claims processed on or after May 1, 2019.

CMA has raised concerns that the new policy is overly broad and will have a negative impact on physicians using the modifier correctly, as it will require them to appeal in order to be paid.

CMA also believes that the policy is vague about exactly when the edit will be triggered and clarification is needed. Specifically, CMA asked Anthem to clarify what diagnoses might fall under the category of “similar” diagnosis. We also asked for clarification on the look back period defined as “recent.”

Anthem advised CMA the edit will trigger for diagnosis codes within the same ICD-10 family and the look back period associated with the edit is two months.

CMA has requested Anthem issue an updated notice to physicians clarifying these points.

While CMA understands the intent of the policy, we remain concerned that, as implemented, the policy is too broad and will create an unnecessary administrative burden on practices that are using the modifier correctly. CMA is continuing the dialogue with Anthem regarding these concerns.

Providers who believe their medical records support payment of the unrelated, significant and separately identifiable E&M service can submit an appeal, including medical records, through Anthem’s Provider Dispute Resolution process for Commercial or Medi-Cal plans.

If your practice has received a denial related to this policy change, CMA wants to hear from you. Practices can contact CMA at (888) 401-5911 or via email at economicservices@cmadocs.org.