Déjà vu All Over Again

Posted March 20, 2019

You might recall that last year Anthem announced their intention to reduce payment for office visits (E&M services) performed on the same day as an office diagnostic or therapeutic procedure (billed using the CPT modifier 25) by 50%. The Kentucky Medical Association, together with the American Medical Association, the Greater Louisville Medical Society and several national specialty societies were able to convince Anthem to withdrawal their ill-conceived policy. This policy, which ignored established CPT rules, not only would have reduced payment to physicians but also delayed patient care and inconvenienced patients.

Prior to 2017, it had become common practice for health plans to send generic appearing mail to physicians with modifications to their provider contracts. These changes often had “opt out” requirements whereby if the physician did not notify the health plan within a limited number of days the contract would be amended. Physicians were unknowingly assenting to changes to their payment rates or even their participation status within plans. The KMA House of Delegates passed a resolution on “Fair Contracting” and the KMA advocacy team worked with Senator Alvarado to gain passage in 2017 of legislation requiring health plans in Kentucky to notify physicians of any material change in their provider contracts with 90 days notice and in a specified orange colored envelope with bold print on the exterior. Last year Anthem proposed their new payment policy regarding the modifier 25 only in an online physician newsletter. KMA objected not only to the policy itself but also pointed out that Anthem had not followed notification requirements of the Kentucky statue. Since the policy change was withdrawn the issue of notification was never specifically dealt with.

Now just last month the same health plan announced in their online Provider Communication their intention to deny payment for office visits which include a procedure (using the modifier 25) if the diagnosis is the same as a “recent” office visit diagnosis. According to published CPT rules, modifier 25 is used to distinguish when the physician’s work goes significantly beyond work normally associated with the minor surgical procedure or service on the same day.  If there was an office visit on some other date, with the same or a different diagnosis, that has nothing to do with the modifier 25 used on the day of the procedure. Anthem’s new policy inappropriately creates a new criterion for use of modifier 25.

Often, particularly for some specialties, the most appropriate care includes an office visit complete with all the usual E&M components and a procedure. This is actually more likely when the patient returns within a short time frame for the same diagnosis – typically because their condition has not improved or the physician felt close follow-up was indicated.  Physicians will face the dilemma of providing uncompensated care or asking patients to return for a separate visit for a needed procedure that could have been done the same day. For the patient another visit may mean another co-pay, more time away from work or other activities, arranging childcare and the stress of the delay.

I know this makes “cents” for the health plan, but does this make any sense at all from a quality care perspective? KMA and I think not! In response, I sent a letter on behalf of KMA to the president of Anthem Health Plans of Kentucky, Kennan Wethington, pointing out that the national standards that exist under CPT should be followed for consistency and if they want to make such a material change to physicians’ contracts they must adhere to Kentucky law requiring proper notification. We can only hope that Anthem will once again realize the new policy is counterproductive to good patient care and repeat history by withdrawing the policy.