Anthem Blue Cross Modifiers

Anthem Modifier 25 Policy

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. As the article indicates, California Medical Association (CMA) has been in direct discussions with Anthem regarding their concerns with this policy including lack of clarity on its parameters and the potential to negatively impact physicians wrongly caught in the policy edit. CMA is continuing their advocacy on this issue and will provide further updates as events warrant.


Anthem Fee Schedule Notification

Anthem Blue Cross recently announced changes to its Prudent Buyer Participating Physician Agreement and fee schedule effective July 1, 2019. According to a notice issued to approximately 1/2 of its PPO network, the plan will be increasing payment for the more commonly billed Evaluation and Management (E/M) services. But, some physicians have reported decreases in payment for other services. Also included in the notification is a change to the Anthem Workers' Compensation reimbursement language reducing reimbursement for those physicians who participate in this product line with Anthem. We would highly encourage physicians to carefully review this proposed amendment and associated fee schedule change to amendment.