HCPro, JustCoding Outpatient - 2019 Issue 19 (May)
Anthem rolls out modifier -25 policy that could deny same-diagnosis E/M claims
May 7th, 2019
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Article Overview
This article examines Anthem’s updated policy affecting evaluation and management claims reported with modifier -25 across its multi-state network. It covers the payer’s stated rationale, concerns raised by coding experts and medical societies, and the general compliance and claims-processing issues provider organizations may need to monitor.
Why This Topic Matters
The policy could affect reimbursement and denial patterns for common E/M billing situations, making it important for coders and billing staff to understand the scope of Anthem’s change and the concerns raised about its alignment with existing coding guidance.
Article Sections
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What the policy means
This section discusses reactions from coding experts and medical organizations, along with concerns about how the policy fits with established coding guidance and payer interpretation.
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What to do now
This section offers high-level operational guidance for tracking denials and reviewing diagnosis-code linkage practices in claims workflows.
What You Will Learn
- How Anthem’s policy update is being described to providers
- Why the modifier-25 issue is drawing concern from coders and medical societies
- What types of claims-processing and denial-monitoring issues may arise
- Why diagnosis-code linkage in E/M and procedure claims is being emphasized
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Compliance professionals
- Physician groups
- Revenue cycle teams
Modifiers Discussed
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