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Academy Advocacy on Modifier 25

Academy Advocacy on Modifier 25

What is the Policy and What has the AAO-HNS Done to Advocate for Membership?

  • 10/1/2017: Anthem notified select members that beginning 1/1/18, E/M services that are eligible for separate reimbursement when reported by the same provider in the same day as a minor surgery ("0" or "10" day global period) will be reduced by 50 percent.
  • 10/3/2017: The Academy's Health Policy Team participated in a conference call with Anthem, during which time Anthem shared their rationale for the policy change and the Academy voiced strong opposition to the inappropriate policy.
    • Anthem states there is a duplication of expenses
    • As noted by CMS in the Medicare Physician Fee Schedule prologue, the duplication of expenses is already removed, so Anthem's claim is false. (see Academy Advocacy Statement)
  • 10/17/2017: The Academy joined a coalition effort, led by the American Academy of Dermatology Association, collaborating with other specialty societies and state societies. The proposed policy will have the greatest impact on Dermatology, followed by Otolaryngology.
  • 11/11/2017: The Academy actively supported AMA Resolution 808 at the AMA House of Delegates Meeting to amend AMA's policy to include provisions that require plans to adhere to CPT rules concerning modifier-25 AND require that both the procedure and E/M are paid at 100 percent of the non-reduced, allowable payment rate.
  • 11/30/2017: Health Policy Staff updated the Academy Advocacy Statement on Modifier 25 for use by members.
  • 12/21/2017: In response to heightened member concern over Anthem’s modifier -25 policy, the Academy has written a letter to Anthem expressing concern with their proposed policy. The letter cites flaws with the rationale used to develop the policy, and requests a meeting to discuss policy and implementation details in-person. To access the comment letter, click here.
  • 12/22/2017: Due to collaborative efforts by the medical community, including the AAO-HNS and our members, Anthem has reconsidered how much it will lower the Modifier 25 E/M service when reported by the same provider in the same day as a minor surgery. According to a recent report from the AMA, effective March 1, Anthem will be decreasing the service value by 25 percent instead of the previously announced 50 percent. The AAO-HNS will continue to work to eliminate the reduction altogether.  
  • 2/2018: Thanks to coordinated, sustained efforts by the AAO-HNS, our members, and others in the House of Medicine, Anthem rescinded its policy across its entire network relating to the Modifier 25 reduction. This advocacy win for the physician community is a great example of how multiple stakeholders using complementary approaches can effect change.

Where and When is Anthem Implementing this Policy?

Prior to December 22, 2017, Anthem had announced gradual implementation as early as January 2018 for eight of its states (California, Connecticut, Kentucky, Maine, Nevada, New Hampshire, Ohio and Wisconsin). Missouri would have experienced this change February 2018; Colorado, Indiana and New York in March 2018. 

However, after heightened advocacy efforts and push back, Anthem announced 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 is a successful step forward in challenging this policy. 

Further, the policy will also be effective upon network contract renewal in Georgia and Virginia.

Anthem will be issuing formal guidance to network physicians communicating these changes within the coming weeks.

2018 Update

Thanks to coordinated, sustained efforts by the AAO-HNS, our members, and others in the House of Medicine, Anthem rescinded its policy across its entire network relating to the Modifier 25 reduction, in February 2018. Anthem announced they would provide formal notification to Anthem’s contracted providers regarding the company’s decision on Modifier 25.

How Can Members Advocate?

  • We encourage you to reach out to your local payer contacts to advocate at the state level, while the AAO-HNS addresses this policy at the national level. 
  • The Academy Template Letter and the Academy Advocacy Statement for E/M and Modifier 25 may be helpful as you reach out to your local payer contacts.
  • If you wish to share any successes or specific challenges while working with your state contacts, please reach out to Claudia Vasquez, MS, Senior Manager of Health Policy & Advocacy, at cvasquez@entnet.org

What are the Next Steps for the AAO-HNS?

  • The Academy will continue to advocate to other national payers to reverse this policy completely nationwide, and work collaboratively with other impacted societies to ensure our efforts are coordinated.