IBC Policy on Modifier 25
Lawrence Brent, MD
Lawrence Brent, MD
As of August 1, 2017, Independence Blue Cross (IBC) has instituted a policy that when a patient is evaluated and a procedure is performed during the same visit, generating and evaluation and management (E&M) code and procedure code with the Modifier 25, reimbursement for the E&M services will be reduced by 50%. This policy has been enacted only for the Philadelphia area and Southeastern PA. The justification for this policy is that the use of the Modifier 25 is considerable higher in Philadelphia and the surrounding areas.
In addition, to have patients return for a second visit just to perform the procedure would be considered a breach of the Professional Provider Agreement (providers shall not discriminate against any member on the basis of the member’s coverage source or amount of payment). Dr. Charles Cutler, as President of the PA Medical Society, sent a strong letter to IBC on June 23, 2017 with the PA Rheumatology Society as one of the undersigning organizations. So far, IBC has not seen fit to change this policy. Certain large organizations may be exempt from this policy due to pre-existing agreements.
The PA Rheumatology Society, the PA Medical Society, as well as multiple other PA subspecialty societies agree that this is very poor policy in that it will eventually reduce access to care. Depending on what each physician does in their own practice, this policy will reduce in-office procedures which for rheumatologist includes intra-articular injections. While not life-saving, these procedures can bring relief and for some patients, enable them to avoid more invasive procedures such as arthroscopic surgery and joint replacement. Reimbursement in Philadelphia and the surrounding counties is already very low compared to other areas of PA and the country while expenses tend to be higher. This will put pressure on salaries making it harder to recruit new rheumatologists in an area of the country that already has difficulty doing so. The PA Rheumatology Society will continue to push for a reversal of this policy going forward.
In addition, to have patients return for a second visit just to perform the procedure would be considered a breach of the Professional Provider Agreement (providers shall not discriminate against any member on the basis of the member’s coverage source or amount of payment). Dr. Charles Cutler, as President of the PA Medical Society, sent a strong letter to IBC on June 23, 2017 with the PA Rheumatology Society as one of the undersigning organizations. So far, IBC has not seen fit to change this policy. Certain large organizations may be exempt from this policy due to pre-existing agreements.
The PA Rheumatology Society, the PA Medical Society, as well as multiple other PA subspecialty societies agree that this is very poor policy in that it will eventually reduce access to care. Depending on what each physician does in their own practice, this policy will reduce in-office procedures which for rheumatologist includes intra-articular injections. While not life-saving, these procedures can bring relief and for some patients, enable them to avoid more invasive procedures such as arthroscopic surgery and joint replacement. Reimbursement in Philadelphia and the surrounding counties is already very low compared to other areas of PA and the country while expenses tend to be higher. This will put pressure on salaries making it harder to recruit new rheumatologists in an area of the country that already has difficulty doing so. The PA Rheumatology Society will continue to push for a reversal of this policy going forward.
