Modifier 25 Reimbursement Changes
Blue Cross Blue Shield of Michigan plans to reduce reimbursement by 50% for certain office visits billed with modifier 25 when a procedure is performed the same day, beginning May 1. The policy focuses on minor procedures and aims to prevent duplicate payment for evaluation services that may already be included in a procedure’s global period, though some services—such as emergency visits and procedures without a global period—are exempt.
Automatic Downcoding Policies
Cigna introduced a policy that could automatically downcode certain outpatient E/M claims if documentation does not support the level of service billed. The insurer says the policy targets a small portion of claims, but provider groups have raised concerns about administrative burden and whether the policy aligns with updated E/M coding guidance.
Peer Comparison Claim Reviews
Anthem Blue Cross of California announced a pre-payment review process that compares a provider’s E/M coding levels with those of peer providers treating similar patients. If a claim appears inconsistent with expected coding patterns, the insurer may request resubmission, suspend the claim, or adjust reimbursement while the claim is reviewed.
Resource: How 3 insurers are trying to tighten E/M billing oversight