APMA’s strong, sustained advocacy stopped a concerning Regence BlueShield Modifier 25 reimbursement policy from taking effect. After APMA raised significant concerns and actively pressed Regence to reconsider the change, Regence announced that it will not implement the policy, which had been scheduled to take effect September 1. The policy would have denied separate reimbursement for E&M services billed with Modifier 25 on the same day as a 0- or 10-day global procedure when an E&M service with the same diagnosis had been billed within the previous 60 days. It would have applied to both commercial and Medicare Advantage plans.
APMA urged Regence to rescind the policy in July, arguing that the change conflicted with CPT and National Correct Coding Initiative (NCCI) guidance and could lead to inappropriate denials for significant, separately identifiable E&M services. APMA worked closely with state components and members in Idaho, Oregon, Washington, and Utah, who provided real-world examples of how the policy could affect patient care.
Those advocacy efforts paid off. In its September bulletin, Regence announced that it “will not implement changes” to its Modifier 25 reimbursement policy at this time.
This reversal represents an important advocacy victory for podiatric physicians and their patients and demonstrates the impact of APMA’s continued engagement with private payers to challenge reimbursement policies that threaten appropriate payment and access to care.
Our work continues. Urge CMS to withdraw its proposed Modifier 25 payment policy.