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Modifier Madness – Put the Patient First

Impact of the Modifier 25 Policy Change

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%. This will apply to claims denoted by the use of Modifier—25 processed on or after Jan. 1, 2018.

For example, when a physician treats a patient for hypertension and osteoarthritis and the patient also complains of a problematic skin lesion, the lesion may be removed during the same encounter. Currently, the E/M service is considered separate and significant and the physician will be paid for both it and the minor surgery at 100 percent.

Starting with claims processed in 2018, the patient may have to schedule a separate encounter to have the skin lesion removed. In addition, if the physician were to discover a suspicious spot during the visit, the patient may have to go home and return another time for a biopsy. This new policy will undoubtedly create undue stress and difficulties.

Although Anthem has stated that they “do not expect physicians to modify their approach to delivering services,” this change has the potential to significantly disrupt care beyond just patient convenience. It will create unnecessary anxiety, cause delays in treatment and increase overall costs for the patient.

It is more important than ever for physicians to continue to strive for correct coding by following CPT guidelines and NCCI rules. Physicians should also be sure to properly document each procedure with the significant, separately identifiable E/M service clearly distinct in the medical record.

KMA has put together a resource guide for physicians on the Modifier 25 policy change.

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