AdministrativeCommercialMarch 31, 2023

Update use of modifier 25 for billing for visits that include preventive and problem-oriented evaluation and management services

On June 1, 2022 (for CT, GA, IN, NH, WI), and July 1, 2022 (for CO and NV), we communicated that Anthem Blue Cross and Blue Shield (Anthem) would begin to implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service is billed with a problem-oriented E/M service and appended with modifier 25.

Provider News articles:

We have since decided to limit this review for claims for members aged 22 and older. Subsequently, we have updated the impacted CPT® codes. For your convenience, we are including an updated communication below:

Anthem will implement additional steps to review claims for evaluation and management (E/M) services submitted by professional providers when a preventive service (CPT codes 99385-99387 or 99395-99397) is billed with a problem-oriented E/M service (CPT codes

99202-99215) and appended with modifier 25 (for example, CPT code 99395 billed with CPT® code 99213-25). This review is limited to claims for members aged 22 and older.

According to the American Medical Association (AMA) CPT Guidelines, E/M services must be significant and separately identifiable in order to appropriately append modifier 25. Based upon review of the submitted claim information, if the problem-oriented E/M service is determined not to be a significant, separately identifiable service from the preventive service, the problem-oriented E/M service will be bundled with the preventive service.

Providers who believe their medical record documentation supports a significant and separately identifiable E/M service should follow the claims payment dispute process (including submission of such with the dispute) outlined in the provider manual.

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

MULTI-BCBS-CM-021013-23-CPN20972

PUBLICATIONS: April 2023 Provider News - Georgia