News Backgrounder: Anthem & the 25 Modifier

Guidance on a common unbundling modifier has shifted frequently during the last decade.

Anthem Blue Cross Blue Shield (BCBS) were set to implement a new processing edit with regard to the use of Modifier 25, effective March 1, 2018, but things didn’t go as planned. Anthem instead submitted a letter to the American Medical Association (AMA) on Feb. 23, 2018 announcing that it was rescinding the new policy … for now. In this letter they indicated that a review will continue, as they feel there are duplicative reimbursements when processing the coding combination of the evaluation and management (E&M) encounter with Modifier 25 appended, along with a minor procedure (0-10-day global service).

Over the years, we have seen BCBS administrators all across the nation trying to implement their own policies modifying reimbursements on either the E&M or the minor procedure when billed on the same date of service. We have also found over the years that many such administrators have either announced similar policies and rescinded them at the last minute, or even implemented them and then modified them back to standard reimbursements. Well, Anthem is no exception to this precedent.

In October 2017, Anthem announced that it would be reducing reimbursements on E&M services billed utilizing Modifier 25 in conjunction to a minor office procedure by 50 percent. However, in January of this year, Anthem revised this opinion and changed the reduction on the E&M service from 50 percent down to 25 percent. This is the now-rescinded policy, as there will be NO reduction at this time.

Now, before we throw hate toward Anthem on this, let’s remember that while not every other carrier is trying to change reimbursement policies on this coding combination, most agree that there are duplicative efforts associated with the decision for the procedure and the E&M encounter. This explanation of why the carriers feel that they are accurate goes back the carriers following Centers for Medicare & Medicaid Services (CMS) guidance. Of course, CMS has its own published guidance, but it includes elements that are open to reader interpretation as well.

In many of my speaking opportunities, Modifier 25 comes up. Inevitably, someone will ask during the session (or privately, after the session) “yikes, I didn’t realize CMS changed their rules; when did this happen?” It would be nice to assuage their shock and awe and tell them, “oh, recently, through CCI quarterly updates.” But that would not be accurate. The harsh truth is these rules have existed for a number of years. As I will note, the surfacing common issues surrounding Modifier 25 have arisen from reviewers’ opinions and interpretation of the guidelines.

Let’s review the rules governing the use of Modifier 25. Since this is an unbundling modifier, the best place to head is the National Correct Coding Initiative (NCCI) Policy Manual (yes, there is an actual policy manual and not just a chart; simply Google and it will pop right up). Guidance on the modifier actually was in the Policy Manual as far back as 2005, and was noted as:

“Modifier -25 is identified in the CPT Manual as a ‘significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.’ This modifier may be appended to an evaluation and management (E&M) code reported with another procedure on the same day of service. The NCCI includes edits bundling E&M codes into various procedures not covered by global surgery rules. If in addition to the procedure the physician performs a significant and separately identifiable E&M service beyond the usual pre-procedure, intra-procedure, and post-procedure physician work, the E&M may be reported with Modifier 25 appended. The E&M and procedure(s) may be related to the same or different diagnoses.”

The most relevant portion of this statement, as it relates to duplicative services, is identified above in bold. CMS indicates here that it would only consider services in excess of a normal pre-procedure evaluation to be reported with Modifier 25, and here rose the first wave of confusion. What is “normal pre-procedure evaluation?” From 2005 through today’s CMS fee schedule, services identified as “minor procedures,” those having a 0-10-day global, do not have a pre-op, intra-op, or post-op allocation on the CMS fee schedule. So, the question becomes (then and now), how do we properly identify pre-procedural work?

Over the next two years (2006-2007), the NCCI Manual saw changes to the representation of the modifier. The combined changes created the following guidance:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25. NCCI does contain some edits based on these principles, but the Medicare carriers have separate edits. Neither the NCCI nor carriers have all possible edits based on these principles.”

We now have the adaption of the wording (highlighted in bold above) “unrelated to the decision to perform.” This change was an attempt to distance the policy from an ill-defined pre-, post-, and intra-operative performance of a procedure with no defined allocation of each. Yet still, ambiguity lies in the chosen words: significant, separate, unrelated, approach each:”

  • Significant: how significant does it have to be? “Gray hair guidance” from our predecessors in the industry has indicated that it must be black and white, but yet that is not what the guidelines state.
  • Separately identifiable: please help me understand how this is different from “significant?” Wouldn’t this merely mean if it is a problem that can be identified that is independent of the reason for the procedure, then it is separate? This does not give us any information on “how much” separate, or how much documentation our provider must include regarding this other issue. If my patient has OA of the knee, which is now causing him hip pain – therefore, we are injecting the knee in an effort to relieve the hip – is this separate?
  • Unrelated to the decision: well, once again, we are met with a dilemma in analyzing documentation for this element. Let’s consider a patient who presents to a retinal specialist for an intravitreal injection of the right eye. Per most providers I have had the pleasure of working with, not only is the right eye evaluated for the procedure today, but so is the left eye to ensure stability and ocular acuity. Also, many of these patients have diabetes, and considerations of their current sugar levels must be evaluated. Again, the question becomes the wording of our guidance. The guidance indicates that it must be unrelated to the decision to perform the procedure; but well, technically, the decision to perform the procedure has been made, and now the provider is doing “additional work” of checking the other eye/knee/skin areas and/or comorbidities of the patient, which could be considered additional work.

In each of these scenarios, there are unanswered questions related to the current guidance. Each reader of this article will have his or her own opinions of each, but again, that opens this up to an interpretive difference of opinion. Is that truly a violation of the actual guidance? Again, it’s a rhetorical question.

The current guidance we have in 2018 has taken this existing language and added minor tweaks in 2013 and 2014, but it has pretty much remained unchanged:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.

Red font     2013 revisions     Blue font     2014 revisions

The 2013 inclusion of the wording “E&M services on the same date” tried to denote that any E&M service was included in the same-day procedure. For this reason, in 2014 the additional wording “in general” was added to try to backtrack the misleading guidance previously published. Still, we have no perfect wording, no truly defined guidance on when, if, or how we can properly provide an E&M and a procedure on same day and accurately report the 25 modifier.

Regardless of what side you reside on (carrier or provider/facility), I ask you to sit back and look at the guidance and review for volatility. I think we can all agree there is no black and white when it comes to Modifier 25. From the carrier prospective, I can certainly understand their take on the CMS stance that repeatedly indicates the decision is not reimbursable. But from the provider standpoint, I can also grasp the fact that we have a “but if we do this, but if we do that” Mentality through which we can support the modifier. This puts us right back where we started: interpretation is all about the eyes of the reviewer and their stance on the published guidance.

Trending CMS National Payment & RVU

While I have bored you with the history of this modifier enough, let me move to one last point. Most carriers base their fee structures on those of the backbone of the CMS system. For that reason, it would be appropriate to look at the reimbursements and RVU allocation for certain minor procedures over the past few years. In our example above, we have utilized the 20610 procedure code (Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance). Of course, you could take any minor procedure and use the CMS fee schedule lookup tool to create an analysis of any service, but for this example, please note below:














































You may note that my analyses for you begin in 2005, and that’s not a coincidence. Remember, that was one of the last years that the CMS stance on the inclusion of the E&M with procedures took a softer tone. It would stand to reason that reimbursements for a procedure should increase with inclusion of the allocation of an entire E&M service, but as referenced above, that is just not the case. As a matter of fact, the reimbursement/RVU allocation is less now than it was 13 years ago. Yet the overhead cost of this service has not decreased; if anything, it has increased. With increased audit demands, implementation of electronic health records (EHRs), HIPAA considerations, and simple annual increases of the costs of doing business (just to name a few), we certainly have not decreased the overhead expenses of these services.

Anthem provides insurance resources for thousands of patients across the states of Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, and New Hampshire. While Anthem did rescind its reimbursement cuts for these supported services, it has made its stance clear in the industry regarding a continued degradation of inclusive patient care. Good patient care does not mean a patient reports to the provider and says “I cannot sleep,” and the provider says “ok, here’s a script for Ambien.” Inclusive patient care is the provider treating the root cause, evaluating probables to ensure that they are ruled out, and putting patient care back to the forefront of medicine.


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Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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