BCBS Michigan to cut 50% from some evaluation/management payments

 This February, BCBS Michigan shared how it will cut reimbursement by 50% for nonpreventive evaluation/management services with modifier 25 that were billed on the same day as procedure codes with global periods of zero, 10 or 90 days.

Modifier 25 is used to indicate separate services provided on the same day. The policy will go into effect May 1, encompassing E/M codes *99202 to *99205 for new patient visits and *99212 to *99215 for established patient visits.

“By doing this, we’ll no longer reimburse for the practice expense component twice,” the insurer said, meaning the insurer intends to not pay double the overhead cost on the same day. 

E/M codes for preventive and administration services and emergency room E/M codes *99281 to *99285 are excluded from the policy.

The change will affect members with BCBS Michigan, Blue Care Network, Medicare Plus Blue and BCN Advantage (participating providers only), and Blue Cross and Blue Shield Federal Employee Program coverage.

Modifier 25 policies have long been met with provider disapproval. In 2018, the AMA sent a letter to the BCBS Association regarding cuts due to member plans’ modifier 25 policies.

These concerns go beyond BCBS. The recent BCBS Michigan update comes nearly three years after a Cigna modifier 25 policy was met with backlash. The policy required documentation submission to justify the modifier’s use. Cigna delayed the policy after the California Medical Association and the AMA, along with more than 100 other physician and healthcare organizations, voiced concerns. 

An Aetna downcoding policy, which included modifier 25, sparked pushback from the American Optometric Association in 2020. Two years prior, Anthem dropped plans to institute 25% cuts on some same-day services.

Despite the backlash, these payer moves may not be unfounded. For example, in the summer of 2018, a network of Florida urogynecologists paid the federal government $1.7 million over allegations of modifier 25 misuse.

https://www.beckershospitalreview.com/finance/bcbs-michigan-to-cut-50-from-some-e-m-payments-with-modifier-25/