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The AOA advocates with private payers to decrease administrative burden for physicians, streamline payment of claims and improve outcomes for patients. Working on behalf of the nation’s 186,000+ DOs and medical students, the AOA physician services team engages with health care payers when policies delay or deny patient care, create added administrative work or otherwise hinder efficient health care delivery.
If you have questions or need assistance, please contact Physician Services or call (312) 202-8194. If your AOA membership is not current and you wish to take advantage of this and all other AOA member benefits, you may join or renew your membership online.
Insurers continue to target claims involving modifier 25 with policies that trigger automatic audits, some may be based on the diagnosis and time between claims, others are based strictly on the use of the modifier. Other denials may be for prepayment clinical validation for a range of modifiers. AOA works closely with members experiencing increased denials or payment delays.
Insurers are targeting claims involving Modifier 25 with policies that trigger automatic audits, based on the diagnosis and time between claims, as well as prepayment clinical validation for a range of modifiers. AOA works closely with members experiencing increased denials or payment delays.
The Physician Services Team meets with Aetna annually to learn about new policies, or as warranted to express concerns from members.
March 2022 E/M Levels 4 or 5 Coding Edits
September 2020 New York New Claim Edits Billing with Modifier -25
September 2020 New Jersey Re-activated Code Edits Modifier -25
The Physician Services Team meets with Anthem monthly to learn about new policies and to express concerns from members.
March 2020 Modifier use reminders – Reimbursement Policies updates
October 2019 The DO Anthem proceeds with Modifier 25 audits, prepayment clinical validation policy
Florida Blue
January 2022 Evaluation and Management for Office or Other Outpatient Services
September 2021 Submitting Claims with Multiple Diagnosis
(Includes Blue Cross Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas)
January 2022 BCBSIL Commercial Claims Editing Coming April 2022
BCBSTX General Reimbursement Information
June 2018 BCBSTX Modifier 25 and 59 FAQs
April 2018 BCBSTX Claim Filing Tips
Oct 2017 BCBSTX Blue Review code-auditing software implementation
Horizon Blue
May 2022 Claim Reimbursement Update: E&M with Modifier 25
November 2021 Horizon E/M with OMT
April 2022 Revised Claim Editing Rules
August 2022 Reimbursement Update: E/M -25
Regence
AOA Physician Services sent numerous letters, including certified letters, emails and calls to multiple Regence and Cambia (Regence parent company) leadership and staff regarding customer service issues and various reimbursement policies, especially related to denials for E&M with OMT services. Regence’s lack of customer service and failure to communicate with the AOA is a very concerning issue. The AOA will continue to aggressively pursue Regence action. It may be helpful if you are having issues with Regence to no avail, to reach out to your state legislators for assistance in seeking Regence response.
November 2022 Chiropractic & Osteopathic Treatments Policy 138
September 2022 Bundling Edits Policy 105
July 2022 Modifier 25; Significant, Separately Identifiable Service
Register for Provider News- The Bulletin & The Connection
Reimbursement Policy Feedback Form
Regence medical policy comments from physicians and other health care professionals
Premera
May 2023 manipulation services: In the osteopathic manipulative treatment section, added that an assessment is considered part of the manipulation procedure code. Also added reference to the CMS National Physician Fee Schedule stating that the OMT codes are classified as minor procedures.
January 2023 E&M Visit: Added third paragraph to indicate that the appending of Modifier 25 is not a guarantee of payment. Added the last paragraph in the policy to indicate appending Modifier 25 to the E&M must be documented in the notes as a separate and distinct E&M service.
March 2022 Modifier 25 Policy Updates: Added clarification on the correct use of Modifier 25 on evaluation and management (E&M) services indicating that appending Modifier 25 does not result in automatic reimbursement unless supported by the documentation in the member’s medical record as a separately identifiable service.
Cigna
Following advocacy efforts by the AOA/AOIA Physician Services Team, the AMA and impacted specialties, Cigna announced that it plans to delay the implementation of their reimbursement policy requiring the submission of office notes with claims submitted with E/M codes 99212-99215 and Modifier 25 when a minor procedure is billed. The policy was scheduled to take effect on Aug. 13, 2022, and again on May 25, 2023. While Cigna remains committed to ensuring appropriate usage and reporting of Modifier 25, they have acknowledged that the policy does not comply with clean claims laws in 24 states. Cigna has not provided a new potential implementation date for the policy.
Official Cigna Notification Banner: Cigna will delay the implementation to require the submission of documentation to support the use of Modifier 25 when billed with E/M CPT® codes 99212 – 99215 and a minor procedure. Cigna will continue to review for future implementation.
Modifier 25 Reimbursement Policy: Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Cigna Evaluation & Management Coding Program
Cigna Information to Establish Medical Necessity
Humana
The Physician Services Team meets with Humana annually to learn about new policies or sooner if warranted to express concerns from members.
October 2019 Humana E/M billed with Modifier 25
Registration Humana Newsletter
UnitedHealthcare
The Physician Services Team meets with UHC monthly to learn about new policies and to express concerns from members.
The AOA has joined the multi-organizational sign-on letter (172 national and state medical specialty societies, patient organizations, foundations, physician groups, hospitals and industry) to UHC asking them not to implement the United Healthcare’s (UHC) gastrointestinal (GI) endoscopy prior authorization program.
June 2023 Prior authorization for gastroenterology endoscopy services
March 2022 UHC Electronic Payment Requirements
2022 Smart Edits FAQ
2022 UnitedHealthcare Smart Edits
2022 UHC Significant, Separately Identifiable Evaluation and Management Service
August 2021 UHC MA Osteopathic Manipulations Policy Guidelines
July 2021 UHC Commercial Manipulative Therapy Medical Policy