MedicaidAdministrativeHigh impact
[Virginia] Use modifier 25 when billing eligible E&M services with XXX procedures
Anthem BCBS·VA·Claims & Billing
Effective date
Nov 1, 2026
We identified it
Aug 25, 2026
Summary
HealthKeepers, Inc. (Anthem Medicaid in Virginia) now requires modifier 25 on all E&M service claims billed with XXX-indicator procedures (injections, infusions, etc.) effective November 1, 2026. Beginning December 1, 2026, claims will be audited to verify the E&M service is significant and separately identifiable from the procedure; claims lacking supporting documentation may be denied or adjusted.
Action Required
By October 31, 2026: Billing team must implement modifier 25 requirement in billing software for all E&M + XXX procedure combinations submitted to HealthKeepers Medicaid. Update encounter forms and provider templates to remind clinicians to append modifier 25 when billing E&M with injections, infusions, or other non-physician procedures. Beginning December 1, 2026: Ensure all E&M claims include robust documentation demonstrating the E&M service is (1) significant and separately identifiable, (2) not redundant with procedure work, and (3) does not include staff supervision or result interpretation. Train providers and clinical staff on documentation expectations immediately. Failure to include modifier 25 or provide supporting documentation will result in claim denials, adjustments, or post-payment recoupment by HealthKeepers Medicaid.