Blue Cross Blue Shield MA' modifier 25 reimbursement reduction policy:
Same-day E/M service with global day procedure update
Effective March 1, 2021, when a distinct evaluation and management (E/M) service is provided to a patient at the same session on the same day as a procedure with a CMS global period indicator of 0, 10, or 90 days:
• BCBS MA will reimburse the lesser allowable service at 50 percent of the fee schedule allowance.
• BCBS MA will continue to reimburse the higher allowable service at 100 percent of the fee schedule allowance.
Background:
- On December 31, 2019 BCBA MA notified physicians that on April 1, 2020 the above reduction policy would be implemented. Due to our advocacy efforts and COVID-19 public health emergency, the policy was postponed with a new effective date of March 1, 2021.
- Since the new date was provided, The Massachusetts Medical Society has been engaged in several conversations with BCBS MA urging to delay implementing the policy that will significantly impact numerous specialties critical to the BCBSMA network and find solutions that safeguard patient access to timely care.
· These engagements included working with leaders from the National and Local Specialties Societies Chapters and The American Medical Association (AMA) Physician Payment Policy Leadership.
· Our Advocacy urged BCBS MA to recognize that the pandemic is surging, and practices have never been more vulnerable. Staffing, patient access, timely visits are significant concerns for all practices. We stressed that now is not the time to make systemic changes that could negatively impact wellness and contribute to further burnout. We also proposed BCBSMA consider the development of a quality initiative instead of cost-cutting initiatives and collaborate with us on coding and claims integrity program for Modifier 25.
· The AMA Team volunteered to review the top five services from BCBS's claims reports with a modifier -25 and provide an analysis of the practice costs and physician work involved in these services and the office visits to demonstrate no overlap in the payment. To be able to share these with employers if needed.
BCBS MA believes they must implement this policy both because they believe there is overlap in expenses and because of the market forces.
- BCBS MA believes there is an overlap in expenses between E/M and procedure codes, BCBS MA remains firm in their position that Medicare’s Payment Advisory Commission (MEDPAC) and 2019 Physician Fee Schedule Proposed and Final Rule reaffirms concerns with significant overlapping resource costs that are not accounted for when a standalone E/M visit occurs on the same day as a global procedure.
- However, we pointed out that the Relative Value Scale Update Committee (RUC) and the Centers for Medicare & Medicaid Services (CMS) already adjust reimbursement for procedure codes typically reported with E/M codes to account for any overlapping costs, including efficiencies time, duplication of materials, and duplication of encounter components.
- Furthermore, we pointed out that RUC removes duplication of expenses through a reduction in the value of procedure codes that are commonly reported with an E/M. This reduction is aimed at removing the valuation of duplicate practice expenses and pre-and post-service physician work. This reduction is automatic and still applies even if the procedure is performed independent of an E/M appended with modifier 25. The RUC reductions to procedure codes are explained in publicly available information contained in the AMA's RBRVS Data Manager.
- BCBS MA has also indicated that this policy is justified and necessary because it is following the market trend. MMS acknowledges that two competitors in the marketplace inappropriately reduce these codes, however it is not justifiable to pursue a similar policy because competitors are. We shared that this reduction in reimbursement is inconsistent with other Blue Cross Blue Shield companies and licensees. Anthem and Blue Cross Blue Shield of Michigan proposed similar modifier 25 reimbursement reduction policies in recent years based on the belief there was an overlap in expense. However, following engagement and discussion with the provider community, including the American Medical Association (AMA) and numerous state and specialty medical societies, both elected to cancel its policy.
- After careful consideration and further discussion with BCBS MA senior leadership of all the points raised above, BCBS MA intends to move forward with the E/M policy change effective 3/1/21.
