Academy Compels Major Private Insurer to Delay Multi-State Modifier -25 Cut

The Academy compelled a major private payer to delay and lessen cuts to reimbursements for office visits bundled with same-day treatment, including intravitreal injections. Since October, we’ve fought Anthem BlueCross BlueShield’s 12-state cut to reimbursements for office visits associated with modifier-25. In response to our advocacy, Anthem says it will delay the cut’s implementation from Jan. 1 to March 1. It will also decrease the cut to these reimbursements to 25 percent, from 50. 

The policy will take effect March 1 in the following states:

• California;
• Colorado;
• Connecticut;
• Indiana;
• Kentucky;
• Maine;
• Missouri;
• New Hampshire;
• Nevada;
• New York;
• Ohio; and
• Wisconsin. 

The Academy continues to fight this cut, which is not appropriate and should not exist in the first place. We believe it could compel physicians to bring patients back to the office for an additional visit to ensure adequate reimbursements. We’re partnering with the affected ophthalmic state societies to halt this cut. 

The Academy has specific guidance on the use of modifier -25. While medically necessary, if you perform the established patient exam solely to confirm the need for the minor surgical procedure, you cannot separately bill the exam. 

Medicare Part B does not require you to append new patient exams with modifier -25 when you perform a minor surgical procedure the same day.