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 168,701 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
Cigna
The Physician Services Team meets with Cigna annually to learn about new policies or sooner if warranted to express concerns from members.
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, 99213, 99214, or 99215 and modifier 25 when a minor procedure is billed. The policy was scheduled to take effect on August 13. 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.
If you received a notice regarding the above mentioned policy you should be receiving this letter explaining the delay.
Official Cigna Notification: The Modifier 25 reimbursement policy update for denial of evaluation and management service codes 99212 – 99215 when performed with a minor procedure without the submission of office notes has been delayed. The policy is under additional review and Cigna will provide follow-up communication and new implementation information when available.
Existing Modifier 25 Policy relating to 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.
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