Fair warning: Anthem's new prepay review policy gives practices time to prepare [Update]

by: Julia Kyles, CPC Jul 9, 2019

What do modifiers 25, 57 and 59 have in common? Yes, they do all contain the number five. But they also could trigger a prepayment review by Anthem BlueCross BlueShield plans as early as Sept. 1.

At least 14 Anthem plans have announced that they will initiate a prepayment clinical validation review process for claims with a number of modifiers, including 25 (Significant, separately identifiable E/M service), 59 (Distinct procedural service), 57 (Decision for surgery), LT (Left side) and RT (Right side) “and other anatomical modifiers,” states the notice published in the July edition of the Providers Newsletter for a variety of Anthem plans.

According to the new policy, registered nurses and coders will review claims to “evaluate the proper use of these modifiers in conjunction with the edits they are bypassing," such as the National Correct Coding Initiative. You’ll be able to appeal denials when you disagree with the findings, the announcement states.

While it is obvious that Anthem wants to crack down on misuse of modifiers that circumvent edits, the scope of the review remains murky. Will frequency of utilization of certain modifiers be enough to trigger prepayment review or will the payer consider additional factors? The policy doesn’t say, but a practice’s best defense is to make sure that it can justify the use of modifiers.

According to DecisionHealth’s review of the policy announcements, Colorado and Nevada will review claims with dates of service on or after Sept. 1. Anthem Medicaid plans will review claims with dates of service on or after Sept. 5. The remainder of plans will review claims with a date of service on or after Oct. 1.

See the list below for plans grouped by the date of service that reviews will begin, as well as a link to the policy announcement. We’ll continue to update it, or you can post a link to a policy we’ve missed in the comments.

Update: The list has been updated to include Kentucky, Missouri, New Hampshire and Ohio.

Sept. 1

Colorado

Kentucky

Nevada

Sept. 5

California Medicaid, Medicare Advantage

Kentucky Medicaid

New York Medicaid

Virginia Medicaid (HealthKeepers)

Wisconsin Medicare Advantage

Oct. 1

Missouri

New Hampshire

New York (Empire BlueCross BlueShield)

Ohio

Virginia

Wisconsin

Blog Tags: claims processing

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