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Anthem’s Evaluation and Management Services Medical Billing Reimbursement Policy

Changes to Anthem's Reimbursement Policy

Changes to Anthem’s Reimbursement Policy

The constant changes to policies regarding medical billing, CPT codes (Current Procedural Terminology), and modifiers can make your head spin. As if it weren’t complicated enough determining whether an E/M visit code (evaluation and management) can be applied to a service provided by the same provider on the same day as a minor surgery, Anthem has also revised their reimbursements when using modifiers 25 and 57.

Making the distinction between E/M services that are included within the global reimbursement for typical pre and post-procedure work on the same day as a procedure or other service, and those that are above and beyond the usual can feel like splitting hairs.

Here are some questions to help determine if a service is eligible:

  • “Does the complaint or problem stand alone as a billable service?”
  • “Did the physician perform and document the key components of an E/M service for the complaint or problem?”
  • “Is there a different diagnosis for a significant portion of the visit? Or if the diagnosis is the same, was extra work above and beyond the usual preoperative and postoperative work associated with the procedure?”

According to Anthem’s revised Evaluation and Management Services and Related Modifiers 25 and 57 Professional Reimbursement Policy, when “a significant, separately identifiable evaluation and management service” is performed on the same day as a minor surgery (“0 or “10” day global period) or an endoscopic, diagnostic or therapeutic procedure, and this evaluation and management service is reported with modifier 25, Anthem’s claim editing system will override the same day medical visit edit, and the E/M service may be eligible for separate reimbursement.

On September 30, 2017, Anthem’s sent a mailing which outlined changes to the policy, indicating that evaluation and management services that are eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery would be reduced by 50% beginning January 1, 2018. This was to cover duplication of indirect practice expenses including, but not limited to, scheduling the visits, staffing, obtaining vital signs, lighting, and supplying the examination room for the same day medical visits.

On January 18, 2018, Anthem again updated this policy. Now, beginning with dates of service on or after March 1, 2018, Evaluation and Management Services (CPT codes 99201-99215) that are eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery will be reduced by 25%. Minor surgeries have a global period of 0 or 10 days and impacted CPT codes are 10000-69999, excluding CPT codes 36415, 36416, and 69210.

If your offices are swamped trying to keep up with the ever-increasing complexity of medical billing and collections, please give us a call at (949) 863-0022. We would love to talk to you about how MBC Systems provides medical billing and coding services paired with collections in the most complete Revenue Cycle Management solution available to health care providers of various sizes and specialties.

Our goal is to provide accurate billing and improved cash flow so our clients can focus on what they do best: providing quality care to their patients.