Anthem reduces proposed cut for services reported with modifier 25; AMA pursuing further changes

December 28, 2017

Today's AMA Advocacy Update included the following article:

Anthem reduces proposed cut for services reported with modifier 25; AMA pursuing further changes

AMA Advocacy UpdateAt its 2017 Interim Meeting, the AMA House of Delegates established new policy to advocate against payment reductions for evaluation and management (E&M) codes appropriately reported with a Current Procedural Terminology (CPT) modifier 25. Considerable concerns regarding this issue have been raised by many state medical associations and national medical specialty societies, most recently in regard to Anthem's new policy, planned for implementation in the first quarter of 2018, to reduce payments by 50 percent for E&M services billed with CPT modifier 25 when reported with a minor surgical procedure code or a preventive/wellness exam.

In late November, the AMA sent a letter to Anthem requesting that the company immediately halt plans to implement its modifier 25 payment-reduction policy. At a subsequent meeting with senior Anthem leadership, the AMA provided information clarifying how the recommendations of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) do not include duplicative physician work or practice expense for procedures typically billed with an E&M service on the same date. The AMA also provided Anthem with further supportive data on those procedures for which practice expense already has been reviewed by the RUC and, using Medicare payment data, shared many procedure codes for which implementation of the proposed policy would result in steep physician payment cuts after accounting for direct expenses. 

Anthem recently informed the AMA that it still plans to reduce payments for E&M services billed with CPT modifier 25, but that payments will be reduced by 25 percent instead of 50 percent, as originally planned. Additionally, the policy will be effective March 1, 2018, in all states where physicians have been notified of the policy change (California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin), which represents an implementation delay for some states. The policy will also be effective upon network contract renewal in Georgia and Virginia.  

While this adjustment is an improvement on Anthem's original planned policy, the AMA still strongly opposes this unjustified reduction of physician payment. The AMA will pursue a follow-up meeting with Anthem in early 2018 to present additional evidence to challenge the revised policy and work with state medical associations and national medical specialty societies to secure further changes from Anthem on this issue. The AMA will also continue to collaborate with the Federation of Medicine to address other recent problematic policy changes implemented by Anthem, including those related to hospital outpatient imaging and retrospective review of payment for emergency services.