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Specialty Societies and the AMA Successfully Challenge Anthem Payment Policy

Source: Emily Hill, PA, AAPM Coding Consultant
Date: March 7, 2018


The AMA and a number of specialty societies, including AAPM, were successful in preventing Anthem from applying a reimbursement reduction when an Evaluation and Management (E/M) service and a procedure were reported on the same day. The AMA and specialty societies responded to the planned change in payment policy by providing information regarding the valuation of procedure codes and the appropriate use of modifier 25. The AAPM was a signatory on the letter sent to Anthem.

Anthem had announced it would be applying a 50% reduction to an E/M service when reported on the same day as a procedure code. In December, it limited the reduction to 25% and gave an implementation date of March 1, 2108. In late February, Anthem announced, after receiving input from physician groups, it would not be applying any reduction when modifier 25 is appended to an E/M service performed on the same date as a procedure.

As you bill for your office-based services, it is important to remember that all procedure codes include the evaluation services necessary to perform the procedure, such as verifying medications and allergies (as appropriate), explaining the procedure, and obtaining consent. These services are included in the procedure code. Modifier 25 is used to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period. It is appropriate to use modifier 25 only when the E/M service is above and beyond the usual pre- and post- work of a procedure performed on the same day as the E/M service.

If you are receiving a reduction in reimbursement for E/M services reported with a procedure code from Anthem or other payers, please notify AAPM so that we can work with the AMA and other specialty societies to challenge these inappropriate policies.

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