Update: E/M with modifier 25 same day as procedure when prior E/M for the same or similar service has occurred: professional
We have identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Anthem’s policy on use of modifier 25.
Beginning with claims processed on or after March 1, 2019, we may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration.
February 2019 Anthem Connecticut Provider Newsletter