“Sweets to the Sweet” Over Modifier 25

Lately we’ve noticed that for patients seen in our wound center, Blue Cross Blue Shield (BCBS) has been denying reimbursement for Evaluation and Management (E&M) services if they are billed on the same day as a procedure, despite the use of a modifier 25 to indicate that a separately billable service was provided.

The explanation of benefits on these BCBS patients stated that the denial of the E&M was due to a “wrong modifier” or “modifier not used.” However, a colleague who dug into this had a telephone conversation with a BCBS representative who said that this new edit, which began on January 1st of 2018, was actually due to the “place of service.” Although that answer implies that BCBS is specifically trying to limit this in the HOPD, it’s been a raging battle for some time in the doctor’s office setting.

For months, the AMA has been battling Anthem BCBS over its decision to cut same day services using the 25 modifier by 50%. Just a few days ago, Anthem Inc. announced that it would reduce the cut by only 25%, which I suppose is a victory of sorts. Patients are negatively affected, because they have to make two trips to the doctor for the services they need if the doctor can only charge for handling one problem at a time. That’s about as NON patient-centered a healthcare policy as you can have.

However, payers rarely cut something totally out of the blue. Usually they take action to control what appears to be an overuse problem, based on their statistical models. The fact is, modifiers 25  and 59 are often abused. I spoke to Kathleen Schaum about this because she discusses the correct use of modifier 25 in the Wound Clinic Business course. She said it’s hard to teach correct usage because clinicians don’t like finding out they have being using these modifiers incorrectly and don’t want to change their approach. I love her quote, which is that physicians ought to use Modifier 25, “kind of like eating Godiva chocolate – SELECTIVELY.”

In any case, whether you can bill an E&M depends on your contracts, local medical policies, NCCI edits, and probably other variables, which may now include site of service.  In the meantime, the BCBS issue I mention above in Texas is different from the Anthem Blue Cross company with which the AMA was negotiating. E&M charges in our wound center are being completely denied if billed with a procedure, and this issue may be linked to the site of service being the hospital based outpatient department. We don’t have an AMA recognized subspecialty, so we are on our own. This is yet another pressure that may be driving wound care out of the HOPD, but I am not sure. Anyway, consider this “heads up.”

And, now I am craving some Godiva chocolate. But it reminds me that when Hamlet’s mother brought “Sweets to the sweet,” she wasn’t bringing chocolate. Those sweets were a funeral bouquet of flowers that she scattered on the grave of Ophelia. So, I’m probably eating my chocolate over the remains of modifier 25.

You can read the AMA story here: https://wire.ama-assn.org/practice-management/win-doctors-anthem-rescinds-pay-cut-same-day-services

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