Wiki Anthem Blue decreased payment for modifier 25

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Has anyone had any luck with appealing BCBS's idea to cut our reimbursement when using modifier 25? Our coding and billing team will appeal based on the visit meeting the E&M without the other items requiring the modifier added on. Just reaching out to see if anyone had any luck or best practices? Anything is appreciated. Thanks
 
It sounds like a hard fast policy to reduce and not based on coding guidelines. Those blanket policies are almost impossible to appeal.
 
My advice would be to appeal if you can show that the E&M service being billed does not include any assessment or decision making that is a part of the reason for the procedure. The reason they made the decision to pay 1/2 of the E&M when submitted with a 25 modifier is that most offices just routinely bill this way without making the analysis as to whether the E&M meets the criteria for significant and separately identifiable.
So take out the components of the issue that is being addressed with the procedure and assess the E&M based only on what is left. If you can support the level that was submitted then appeal it with that logic. If you cannot support the E&M it should not have been submitted.
 
From what we are understanding directly from our Anthem Physician Liaison, this will not be an appeal situation. The policy is not a coding/billing policy, it's a reimbursement policy.

I'm curious what other offices are planning to do in response to this. Unfortunately, Anthem is our largest commercial payer covering about 2400 active patients. We are primary care and everything from vaccine administration to cerumen removal to excisions are done the same day as an office visit for chronic conditions. This will have a huge impact on our office.
 
Does anyone know of OTHER carriers practicing this reimbursement policy (i.e. reducing E/M with modifier 25).

If so, can you please provide links to the payment policies (such as I did in the previous reply).
 
Harvard pilgrim as well. I'm guessing all the Massachusetts based payers. The one I used to work for we were going to but did not want to be the first payer to do it. Id expect more to join the bandwagon.

https://www.harvardpilgrim.org/pls/...AYMENT POLICIES/H-2 EVALUATION-MGT_101517.PDF

Significant, Separately, Identifiable E&M with Global Day Service—
Same DayPolicy applies to all professional services performed in an office place of service - when significant, separately identifiableE/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of0, 10, 90 or YYY is performed on the same day, the E&M service will be reimbursed at 50% of the contracted allowable.When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
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office visit - not covered

I had a patient call today questioning their bill. BCBS did not pay for the E&M code and made the patient responsible for the full billed amount of the E&M code only. They state the code is "not a covered service." We billed it with modifier 25, 96372 and the Jcode. BCBS paid for the 96372 and Jcode. I submitted an appeal even though it wasn't exactly denied, but we will see what they say.

Has anyone else experienced this? I cannot find any other info and it leads me to believe it has something to do with the reduction using mod 25. And if they are just going to place the responsibility on the patient, would you bill the patient the full billed amount or would it be okay to offer a discount?

I'm worried this will continue to happen so any advise would be extremely appreciated!

Thank you!
 
Was the reason for the visit to receive the injection? If you have documentation that supports the E&M as a separately identifiable service then I would appeal the denial. I would not think billing the patient is the right thing to do. If you cannot support the use of the 25 modifier then it should not have been billed. Without the note it is difficult to advise more.
 
mitchellde said:
Was the reason for the visit to receive the injection? If you have documentation that supports the E&M as a separately identifiable service then I would appeal the denial. I would not think billing the patient is the right thing to do. If you cannot support the use of the 25 modifier then it should not have been billed. Without the note it is difficult to advise more.
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THANK YOU SO MUCH FOR RESPONDING! The patient actually came in for flu like symptoms, had a flu test and an antibiotic shot. BCBS paid 80% of those services, patient responsible for her co-ins. So the reason for her visit was not for a shot at all.... I guess I just answered my own question! Hoping the appeal works.

If anyone else has had any issues with BCBS not paying for the E/M code in a similar situation I'd be interested to know. I can't find anything from BCBS about it.. I'd like to get ahead of any more of these. Thank you!
 
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