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AAO-HNS Comments on Anthem BCBS of Virginia’s Modifier 25 Policy (7/23/2019)

AAO-HNS Comments on Anthem BCBS of Virginia’s Modifier 25 Policy (7/23/2019)

On July 23, the Academy sent a letter to Anthem BCBS of Virginia expressing our strong opposition to their revised modifier 25 reimbursement policy.  According to the new policy, and effective for dates of service May 1, 2019 and beyond, Anthem BCBS may deny an E/M service, with modifier 25, billed on the same day of a related procedure when there is a recent service or procedure for the same or similar diagnosis.  This policy mirrors Anthem’s national policy which the Academy commented on last month.

The AAO-HNS comment letter cited flaws with the rationale used by the company in developing this policy. It calls on Anthem BCBS to immediately reverse this policy by providing full reimbursement for all clinically appropriate E/M services.  The letter also requested clarification on two issues: the definition of recent or related procedures and what is considered the same or similar diagnosis.

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