Updated – February 26, 2018
After strong opposition, Anthem has rescinded its policy to reduce payment for E/M services submitted with modifier 25. It’s a small victory for medical practices. You can read the details here and now, I can dial back my outrage meter. It was an unreasonable, unilateral action. Alright, I’ll dial back my outrage meter a little more.
Original post below: (January 2018)
Anthem to discount some E/M services by 50%
In some states, Anthem has a new policy. I’m mad about it, and I think you will be, too. Anthem will reduce the payment for E/M services reported with modifier 25. This will reduce a practice’s E/M payment by 50% when the E/M service is done on the same day as a procedure or when a problem oriented visit is done on the same day as a preventive medicine service.
Why? Because they can.
I’m the first to admit there are times I audit a note billed with a minor procedure (procedure with 0 or 10 global days) and an E/M service and say, “Only the procedure is documented. Don’t automatically bill an E/M service.” All of us who regularly review notes have said that at times. But, let’s think about the implications of this.
- A patient presents with abnormal uterine bleeding, the physician assess the condition, takes a history and decides to do an endometrial biopsy at the visit. The physician will be paid half of the fee for the evaluation of the abnormal bleeding.
- A pulmonary physician is called to the ED to see a patient who is SOB and coughing up blood. After evaluating the patient, examining the patient, reviewing the labs and past medical records, the physician decides to do a bronchoscopy. The pulmonologist will be paid 50% for the evaluation of the patient.
- A family physician sees a patient for a preventive medicine service and also treats a moderate exacerbation of COPD. The physician will be paid 50% for treating the COPD.
- A GI doctor evaluates a patient with rectal bleeding and does an anoscopy. The doctor will be paid 50% for the evaluation because of the anoscopy!
Anthem is de-valuing the separate and distinct evaluation of the condition that occurs prior to the decision to perform the procedure. Anthem is de-valuing the work of the physician, nurse practitioner and physician assistant. This is going to hit a lot of specialties, hard.
And, as for the problem oriented visit and preventive service on the same day, these are two separate and distinct services. See the CPT Assistant, July 2009 for the rule and explanation.
Of course, there is an overlap in medical and social history and exam. But providing a preventive medicine service is distinct from working up new onset bright red blood, per rectum or management the patient’s diabetes, sleep apnea and osteoarthritis. This is a blow to primary care. CMS says it wants to support primary care, but Anthem is saying, “who cares?”
Call your state medical society and your specialty society and ask them to protest this policy and fight this arbitrary change. Tell them: Anthem should follow CPT rules.
I’m mad. I bet you are too.
Update (January 2018)
After discussions with the AMA, Anthem said it would change the percentage from a 50% reduction to a 25% reduction, with a March 1, 2018 implementation date. The affected states are California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin.