Upcoming Anthem Policy Change: Prepayment Coding Review for Certain Modifiers
Starting Apr. 1, 2025, Anthem implemented a new prepayment coding validation review process for outpatient claims. This update affects claims submitted with specific modifiers, ensuring compliance with established reimbursement policies and National Correct Coding Initiative (NCCI) guidelines.
What’s Changing?
Anthem’s revised review process will include an assessment of claims that feature the following modifiers:
- Evaluation and Management (E/M) and Procedural Modifiers: 24, 25, 58, 59, 78, 79
- Anatomical Modifiers: E1–E4 (eyes), F1–F9 (fingers), TA (toe), LT (left side), RT (right side), LC (left circumflex), LD (left descending), RC (right circumflex), LM (left main), RI (right side)
- Distinct Procedural Modifiers: XE (separate encounter), XP (separate practitioner), XS (separate structure), XU (unusual non-overlapping service)
These modifiers are often used to indicate that a service was separate from another service or that a procedure was performed under specific clinical circumstances. However, inappropriate use of these modifiers can lead to incorrect claim reimbursement, which is why Anthem is increasing scrutiny before payment.
Why the Change?
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