AAO-HNS advocates on Anthem’s Modifier 25 policy

March 2018 – Vol. 37, No. 2

As many AAO-HNS members are aware, in the fall of 2017, Anthem announced its plans to reimburse Evaluation and Management (E/M) services at a 50 percent rate when a significant, separately identifiable E/M service (appended with the 25 modifier) and surgery/diagnostic procedural services are performed on the same day. This policy was scheduled to be implemented in 14 states as early as January 2018.

In a letter to Anthem expressing concern with the proposed policy, the AAO-HNS advocated that the proposal was inconsistent with the Centers for Medicare & Medicaid Services (CMS) reporting rules and the AMA Current Procedural Terminology (CPT) codes, guidelines, and conventions. The letter cited flaws with the rationale used to develop the policy and requested a meeting to discuss policy and implementation details in person.

As a result of collaborative efforts by the medical community, including the AAO-HNS and our members, Anthem has reconsidered how much it will lower the Modifier 25 E/M service when reported by the same provider in the same day as a minor surgery. Effective March 1, Anthem will decrease the service value by 25 percent instead of the previously announced 50 percent. The AAO-HNS will continue to advocate to eliminate the reduction altogether, including state-based grassroots efforts.

To stay updated on the latest AAO-HNS advocacy efforts, and for resources to appeal this policy, visit www.entnet.org/modifier-25-advocacy.

Read the latest updates on this policy in the April Bulletin.