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Anthem – Update Modifier 25

Published Jan. 31, 2018

KMA helps reduce initial reimbursement cut from 50 to 25 percent

In October, Anthem announced that evaluation and management (E/M) services, historically eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery, would be reduced by 50%.

After discussions between Anthem and medical associations at the national, state and local levels, including KMA, Anthem has announced that the reduction will now be 25%, effective with dates of service on or after March 1, 2018.

While 25% is an improvement from 50%, Anthem’s policy still fails to recognize one of the basic rules of CPT, which is the proper use of modifiers. The modifier 25 is used to recognize physician work that goes significantly beyond what is normally associated with a minor surgical procedure on the same day.

The appropriate use of modifier 25 is not to pay for “duplicative services relating to fixed/indirect practice expense.” Instead it is used to account and pay for time, technical skill, effort and most importantly, medical judgement by the physician. That is the main purpose of the modifier 25.

KMA published an op-ed in the Lexington Herald Leader on Jan. 5 critical of this and several other Anthem policies, which can be viewed here.

Recently, Anthem notified providers they will now conduct post-service reviews of professional modifier 25 claims and may request additional documentation related to the services provided.

You may address questions directly to Anthem at: Answers@Anthem>Reimbursement or contact Lindy Lady at KMA at

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