Opposing payer cuts for modifier -25

A number of payers, including Anthem, have begun reducing payment by 50% for evaluation and management (E&M) services billed with procedure codes. Although this policy is currently only applied to procedures with a global period – and not to allergy testing or injections – there is concern that allergy services could be next.

The College Advocacy Council has been working with other medical societies to attempt to roll back these cuts. So far there has been partial success. Anthem has agreed to reduce the cut to 25% but medical societies and state medical associations around the country are urging Anthem to eliminate the cut entirely. Sound and established coding principles state that modifier -25 is only to be used when the office visit is a separate and distinct service unrelated to the procedure. In other words, there is no overlap in the services that justifies a reduction in payment.  

If you experience any reductions in reimbursement for E&M services billed together with allergy testing or other allergy services, please let the Advocacy Council know so we can investigate and take action if needed. We will continue to follow this issue and let you know of any changes - including any efforts to apply this policy to allergy services.

Advocacy Issue: 
Billing, Coding & Payments