MMA Challenges BCBS MN Policies that Reduce Payment for Same-Day Services

August 29, 2024

In a follow-up letter sent to the chief medical officer at Blue Cross Blue Shield of Minnesota (BCBS MN) on August 14, the MMA challenged the insurer on three of its publicly posted reimbursement policies that reduce physician payment for same-day services. 

Specifically, BCBS MN reduces payment for evaluation and management (E/M) services by 20% to 50%, depending on product line (i.e., commercial, Medicaid, Medicare), when appended with modifier 25. The Common Procedural Terminology® (CPT®) coding guidelines require that providers append modifier 25 to an E/M service to “indicate that a patient’s condition required a significant, separately identifiable E/M service above and beyond that associated with another procedure or service by the same physician…on the same date.”  

For example, if a patient comes in for a 25-minute outpatient visit, and during that visit the physician discovers a wart that the patient wants removed, the physician will bill the outpatient visit E/M code, appended with a modifier 25, in addition to the procedure code for the wart removal. In this case, depending on product line, BCBS MN would reduce the reimbursement for the 25-minute outpatient visit by 20% to 50%. 

In September of 2023, the MMA met with BCBS MN leadership to emphasize how their modifier 25 policies deter the provision of additional, unscheduled services patients need; could cause delays in care for BCBS MN members; and neglect to acknowledge the regular adjustments made to the relative value units of CPT® codes that are billed with E/M codes more than 50% of the time. These adjustments aim to prevent duplicative valuation of practice expenses and pre-/post-visit physician work (AMA, p. 11). At the time, BCBS MN indicated that similar policies are adopted by most other Minnesota health plans and, as such, the policies of BCBS MN are within community standards. 

After several months of research and conversations with Minnesota health plans, MMA staff confirmed that BCBS MN’s modifier 25 policies are inconsistent with most others. As stated in the August 14 letter: 

“Based on publicly available information confirmed by health plan representatives, MMA staff have learned that, of Minnesota’s seven largest health plans, BCBS MN is the only health plan with modifier 25 payment reduction policies that apply in all cases that a modifier 25 is used. Three other health plans have modifier 25 payment reduction policies that apply only when the modifier-25-appended E/M service is billed with a same-day preventive service (e.g., CPT codes 99381-99387, 99391-99397). Three other health plans have no modifier 25 payment reduction policies whatsoever.” 

According to AMA coding experts, preventive service codes are billed less commonly with E/M services and, as such, they don’t meet the current threshold that warrants adjustment for duplication.  

The MMA will update its members on the response from BCBS MN. Please contact Adrian Uphoff, health policy analyst, with questions.