In May 2024, Tanya W. Spirtos, MD, president of the California Medical Association (CMA), sent a letter to Aliza Arjoyan, senior vice president of provider partnerships and network management for Blue Shield of California. In it, Dr. Spirtos expressed CMA members’ concerns about a recent reimbursement policy change the insurer had announced regarding evaluation and management (E/M) services billed with the Current Procedural Terminology (CPT) modifier 25. The new policy would reduce by 50% reimbursement for any non-preventive E/M service appended with modifier 25 and billed with a minor procedure code.
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December 2024In her letter, Dr. Spirtos charged that Blue Shield’s proposed policy change would, in effect, penalize physicians for administering “efficient, unscheduled care,” provided during time slots that many physicians hold open in anticipation of the “20 to 30% of patients who may require same-day procedures,” as noted in the letter.
According to Erin Mellon, vice president of strategic communications for the CMA, this recent move by Blue Shield of California to reduce reimbursement on modifier 25-billed services is not unique. “The Blue Shield modifier 25 policy was just the latest in a series of attempts of payers to contain costs—often in violation of California law and industry standards—by bluntly penalizing physicians using the modifier appropriately,” Mellon said.
Such payer pushback on reimbursement for modifier 25-billed E/M services has been an ongoing challenge, said Lance A. Manning, MD, the advocacy coordinator on the board of directors for the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). “Problems with the 25 modifier have been cyclical over the last decade,” he said. “The AAO-HNS has successfully defended the proper use of this modifier several times during that period. Unfortunately, the private payers then bring this up several years later, and our physicians must face the same problem again.”
Separate Service
As described by the American Medical Association (AMA), modifier 25 “is used to indicate that a patient’s condition required a significant, separately identifiable E/M service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional on the same date. This service must be above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure or service that was performed on that same date, and it must be substantiated by documentation in the patient’s record that satisfies the relevant criteria for the respective E/M service to be reported” (American Medical Association. https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf).
R. Peter Manes, MD, associate professor in the division of otolaryngology, department of surgery at Yale School of Medicine in New Haven, Conn., is the Relative Value Scale Update Committee (RUC) advisor for the AAO-HNS. He offers this hypothetical description of the appropriate use of modifier 25 in the otolaryngology world: “One very common complaint we see in our practice is hoarseness. At times, we are unable to get a good exam of the vocal cords using a mirror, which would be an indirect laryngoscopy. This would be a good time to perform a procedure and use a flexible scope through the nostrils and examine the vocal cords that way. In that case, we would append a 25 modifier to an E/M visit because we had to do an additional procedure beyond the scope of the E/M to adequately evaluate that patient’s particular problem.”
Currently, one-third of our office visits are appended with the 25 modifier. —Kevin Watson, chief executive officer of Raleigh Capitol Ear, Nose & Throat