Anthem Reduces Payments for E&M Visits with Modifier 25

Members & Publications


December 29, 2017

The American Medical Association (AMA) recently announced that they had had some success in persuading Anthem Health Care to change their new policy of reducing payment for an E&M visit by 50% when it is provided with certain procedures on the same date of service, by the same practitioner, to the same patient, even with proper application of modifier 25. Although Anthem rejected the request to rescind their new rule, it has agreed to reduce such payments by only 25% rather than the originally proposed 50% reduction. The policy will take effect on March 1, 2018, in California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin, as well as upon network contract renewal in Georgia and Virginia.

In general, E&M visits on the same day as procedures with a global period are not paid separately as they are regarded as being part of the procedure. However, if the E&M service is one which is separately identifiable from the procedure, the attachment of modifier 25 will allow the E&M service to be paid separately. According to CMS instructions, “It (modifier 25) should be used when the E/M service is above and beyond the usual pre- and post-operative work of a procedure with a global fee period performed on the same day as the E/M service…Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented.”

Click here to access the CMS instructions.

AMA leadership met with Anthem leadership to share information about how the AMA/Specialty Society Relative Value Scale Update Committee (RUC) determines practice value and to share (using Medicare payment data} many procedure codes for which implementation of the proposed policy would result in negative physician payments after accounting for direct expenses.

Anthem’s original decision to only pay 50% of the E&M service, even when modifier 25 is properly attached, runs contrary to normal billing conventions and both the AMA and other medical organizations requested that they reconsider their decision. Although the change described above (reduction of 25% rather than 50%) represents an improvement, the AMA remains strongly opposed to “this unjustified reduction of physician payment,” and will continue to work with state medical associations and national medical specialty societies to secure further changes in Anthem’s policy in this area. Physiatrists who have been adversely affected by Anthem’s policy are encouraged to share information with AAPM&R to allow us to actively participate in the endeavor to rescind the policy in its entirety.

Legislation Introduced to Alleviate Impact of Conversion Factor Cut for 2021

Nov 09, 2020

Last month, two bills were introduced in the House proposing solutions to the estimated 10.6% Physician Fee Schedule conversion factor cut expected to go into effect January 1, 2021.  The bills offer some relief to the cut, but do not reflect a comprehensive or long-term solution.  AAPM&R has therefore chosen to remain neutral regarding these bills. 

Your Academy continues to advocate for a permanent solution to the conversion factor cut while maintaining the important payment increases to office and outpatient evaluation and management services.