decisionhealth Newsletters, Coder Pink Sheets - 2019 Issue 6 (June)
Mind your modifiers: Anthem rolls out modifier 25 policy that could deny same-diagnosis E/M claims
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Article Overview
This article explains a payer policy update from Anthem that affects evaluation and management claims submitted with modifier 25 across multiple states. It summarizes the concern among coding professionals and medical societies, references broader coding guidance from the AMA and other organizations, and highlights the kinds of claim-handling and documentation issues practices may need to monitor. The piece is relevant to coders, billers, compliance staff, and clinicians who submit same-day office visit and procedure claims under commercial insurance.
Why This Topic Matters
Payer edits that alter how modifier 25 claims are reviewed can affect reimbursement, denials, and billing workflow. Understanding the scope of the policy and the concerns it raises helps practices prepare for claim review changes and documentation questions.
Article Sections
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Policy update and rollout
Summarizes the insurer’s multi-state provider communications and the general scope of the policy change. Notes the timing of the rollout and the claims scenario it targets.
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What the policy means
Describes reactions from coding experts and medical societies, along with concerns about how the policy aligns with broader coding guidance. Discusses questions that remain about interpretation and enforcement.
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What to do now
Offers general next-step considerations for practices reviewing claim denials and diagnosis-code linkage workflows. Focuses on operational awareness rather than substantive coding instruction.
What You Will Learn
- How a commercial payer is changing its review approach for certain same-day evaluation and management claims
- Why the policy has raised concerns among coding professionals and medical societies
- What operational issues practices may need to monitor when submitting claims and linking diagnoses
- Which organizations and stakeholders are discussed in relation to the policy
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Compliance staff
- Physicians and practice managers
- Dermatology practices
- Primary care and specialty practices submitting E/M claims
Modifiers Discussed
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