In recent months, payers across the country have tried tightening policies to get a better grip on evaluation/management coding.
While payers often say the policies aim to control costs or combat fraud, these more restrictive policies are often met with provider backlash. Here are three insurer policies from the past few months — and where they stand.
Targeting modifier 25
Starting in May, BCBS Michigan will cut reimbursement in half for some nonpreventive services with modifier 25, a code indicator of separate services provided on the same day.
Specifically, the insurer is focused on cutting payments for office visits when the patient has a procedure on the same day. The policy could cut spending for duplicative evaluation work, since procedures with a global surgical period — a timeframe that covers related services based on a surgery’s severity — of zero, 10 or 90 days already include some level of evaluation. This policy is currently set to go into effect for services provided on or after May 1.
A handful of payers have implemented modifier 25 policies but have met some resistance. BCBS North Carolina rescinded their policy for minor procedures less than two months after announcing it in 2024. Cigna delayed its own modifier 25 policy more than once, as providers expressed concerns over administrative burden.
Automatic downcoding
Cigna launched a downcoding policy in October, but paused implementation for some California products as the insurer sought review from the state’s Department of Managed Health Care.
Under the policy, certain outpatient codes would be downgraded if they do not meet complexity standards. Cigna clarified automatic changes would not occur for all claims. The insurer also said the change would not affect nearly 99% of in-network providers, as well as 97% percent of those who bill level 4 and 5 E/M codes, which are more complex. Cigna said the policy would target claims where the providers’ submitted information does not substantiate the level of service billed.
Appealing via fax was one concern for the California Medical Association. The organization also questioned whether the policy aligns with the state’s claims payment and disclosure laws. In 2021, revisions to E/M guidance allowed for providers to code based on time or medical decision making, which could pose a potential conflict with the policy.
Comparing provider claims
A November notice from Anthem Blue Cross of California outlined a pre-payment review process. The policy would compare E/M coding levels across peer providers caring for similar risk-adjusted members. If the submitted E/M level does not align with the supported level, Anthem could request resubmission, suspend the claim or adjust reimbursement.
Anthem Blue Cross of California pushed out implementation of its downcoding policy until April, which is also pending review by the California Department of Managed Health Care.
