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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. The policy would be effective across all of Anthem's 14 states (i.e., California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, Virginia, and Wisconsin).
  • 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.
  • 2/22/18: The Academy sends a comment letter to Independence Blue Cross of Pennsylvania, addressing their modifier 25 policy. The comment letter referenced rationale for why the policy was inconsistent with CMS reporting rules and the AMA CPT codes, guidelines,  conventions, and ultimately flawed.
  • 5/24/18: The Academy joined with the Medical Society of New Jersey and more than 40 other state and national medical associations to submit comments to AmeriHealth New Jersey and Independence Blue Cross. The joint letter  expressed concerns with AmeriHealth's modifier 25 policy.
  • 6/1/2018: In response to heightened member concern over Health Net’s modifier -25 policy, the Academy has written a letter to Health Net expressing concern with their proposed policy (effective 7/1/18). The letter cites flaws with the rationale used to develop the policy, and requests Health Net immediately reconsider their policy. To access the comment letter, click here.
  • 6/19/2018:  Health Net, due to the Academy’s advocacy letter and coordinated opposition efforts with the California Medical Association (CMA) and other medical societies, confirmed its decision to rescind the planned Modifier 25 policy in California.  The rescinded policy would have cut by 50 percent the reimbursement for an evaluation and management service when billed with a minor surgical procedure or a preventive visit.  Health Net had originally agreed to delay the Modifier 25 policy implementation to July 1 before this announcement.  CMA’s official statement can be found here.

How Can Members Support Academy Advocacy Efforts?

  • We encourage you to reach out to your local payer contacts to advocate at the state level, while the AAO-HNS addresses modifier 25 policies 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 at the local level, or if you wish to share local 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.