Anthem’s new E&M codes policy to go into effect in Georgia upon renewal

The following message is from Jack Resneck Jr., M.D., the chair-elect of the American Medical Association’s Board of Trustees… 

At its 2017 Interim Meeting, the AMA House of Delegates (HOD) established new policy to advocate against payment reductions for evaluation and management (E&M) codes appropriately reported with a Current Procedural Terminology (CPT) modifier 25. Considerable concerns regarding this issue have been raised by many state medical associations and national medical specialty societies, most recently in regard to Anthem’s new policy to reduce payments by 50 percent for E&M services billed with CPT modifier 25 when reported with a minor surgical procedure code or a preventive/wellness exam. Anthem had announced that it would be implementing this policy in a number of states in the first quarter of 2018.

In late November, the AMA sent a letter to Anthem requesting that the company immediately halt plans to implement its modifier 25 payment reduction policy. Per the AMA’s request, senior Anthem leadership attended a meeting with AMA leadership in early December to discuss this issue. Anthem was provided with information clarifying how the recommendations of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) do not include duplicative physician work or practice expense for procedures typically billed with an E&M service on the same date. The AMA also provided Anthem with further supportive data on those procedures for which practice expense already has been reviewed by the RUC and, using Medicare payment data, shared many procedure codes for which implementation of the proposed policy would result in negative physician payments after accounting for direct expenses. Anthem agreed to review the data provided by the AMA and respond with any changes to its planned policy.

On December 22, Anthem informed the AMA that it still plans to reduce payments for E&M services billed with CPT modifier 25, but that payments will be reduced by 25 percent instead of 50 percent, as originally planned. Additionally, the policy will be effective March 1, 2018, in all states where physicians have been notified of the policy change (California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin), which represents an implementation delay for some states. The policy will also be effective upon network contract renewal in Georgia and Virginia. Anthem will be issuing formal guidance to network physicians communicating these changes within the coming weeks.

While this adjustment is an improvement on Anthem’s original planned policy, we still strongly oppose this unjustified reduction of physician payment. We will conduct additional analysis of the codes and services involved. In addition, we will pursue a follow-up meeting with Anthem in early 2018 to present evidence to challenge the revised policy. We will also continue our work with state medical associations and national medical specialty societies to secure further changes in Anthem’s policy in this area. 

We also recognize that Anthem has recently implemented several other policies that are of significant concern to the Federation of Medicine and our patients, including those related to hospital outpatient imaging and retrospective review of payment for emergency services. We will also continue to work with our Federation colleagues to address these other problematic Anthem policies.

Contact Heather McComas at heather.mccomas@ama-assn.org with questions.