Blue Cross Blue Shield of Michigan said it will push back the start date of its modifier 25 policy from May 1, according to a company statement and an April 15 provider alert posted by the Michigan State Medical Society.
In February, BCBS Michigan said 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. However, the insurer has since axed the 90-day global period, saying its inclusion was an error, and those claims should be appended with modifier 57.
Modifier 25 is used to indicate separate services provided on the same day by the same healthcare professional. The policy would encompass E/M codes *99202 to *99205 for new patient visits and *99212 to *99215 for established patient visits.
“Blue Cross remains committed to collaboratively working with providers to ensure our members have access to high-quality, affordable healthcare,” the insurer said in an April 17 statement shared with Becker’s. The insurer did not confirm a new effective date. In an April 16 news release, the Michigan State Medical Society said it appreciated the opportunity to collaborate as the insurer revisited the policy.
Recent revisions to exclude 90-day global periods limit the policy to minor procedures. That update also said that an emergency room visit within one calendar day and nonsurgical procedures with no global period will be exempt. Since its introduction, the policy did not encompass E/M codes for preventive and administration services and emergency room E/M codes *99281 to *99285.
The change will eventually affect members with BCBS Michigan commercial, Blue Care Network, Medicare Plus Blue and BCN Advantage (participating providers only), and Blue Cross and Blue Shield Federal Employee Program coverage.
“By doing this, we’ll no longer reimburse for the practice expense component twice,” the insurer said previously, meaning the carrier intends to not pay double the overhead cost on the same day.
Modifier 25 policies have long been met with provider disapproval.
“While the removal of the 90-day global period from the policy represents a clarification, the reduction in reimbursement for modifier 25 services associated with minor procedures remains a significant concern for many specialties,” a March 5 statement from the Michigan State Medical Society said. “MSMS will continue aggressive advocacy efforts and provide updates as discussions with BCBSM progress.”
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, though. Roughly three years ago, Cigna delayed a modifier 25 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.
This story was updated April 17.
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