CPMA Mounts Major Pushback Against New Anthem Modifier 25 Policy

CPMA Mounts Major Pushback Against New Anthem Modifier 25 Policy

 

Dear CPMA Members:

Anthem Blue Cross is at it AGAIN! 

Anthem has announced the following reimbursement policy (or lack thereof) in California:

For commercial claims processed on or after March 1, 2019, Anthem will deny an E&M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record for the same provider (or a provider with the same specialty within the same group TIN).  This policy will also apply to its Medi-Cal line of business beginning with claims processed on or after April 1, 2019.

The California Podiatric Medical Association (CPMA) is very concerned with the adverse impacts of this new policy upon our member doctors. CPMA’s Health Policy Chair, Franklin Kase, DPM has already been in contact with Anthem, and has ardently challenged the new policy.  Anthem claims these denials are happening at a very low rate and, in response to our opposition, they are asking CPMA to provide examples of these denials from our members’ practices.

In order to continue to oppose this policy, we need you to share examples (PLEASE redacted patient information) of these denials found in your Explanation of Benefits (EOBs). Please review your EOBs for these denials and share them with CPMA when they are found. We are collecting any and all responses through the end of June, at FAX: 916-448-0258 or afinley@calpma.org.  Please put Anthem 25 Modifier in the subject line. 

The denial codes you may see are:

CO-182: The modifier code does not correspond with the procedure code billed. 

CO-97: This service is denied because it is considered to be part of another service already performed and reimbursed.  

CO-234: The service is denied because the service billed is not covered separately and is considered part of the member's primary procedure.  Participating providers are prohibited by contract from balance billing the member for this charge. 

CO-236: Service is denied because it is incidentally based on the National Correct Coding Initiative (NCCI) as published/maintained by CMS (Center of Medicaid/Medicare Services). Participating providers are prohibited by contract from balance billing the member for this charge.                                           

CPMA maintains that it is completely unreasonable to arbitrarily diminish the value of work done by providers – in the best interest of their patients - that this new policy dictates.  

Anthem has put the burden on CPMA and its members to validate our opposition. We need your help in getting the word out to collect these denials as evidence to enable us to succeed in these efforts. Again, please provide any and all examples of these Anthem denials to CPMA at FAX 916-448-0258 or Email as soon as possible, but no later than June 30.