MedicaidDocumentationHigh impact
[Ohio] Use modifier 25 when billing eligible E&M services with XXX procedures
Anthem BCBS·OH·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Aug 25, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicaid in Ohio now requires modifier 25 when billing E&M services performed with XXX procedures (those with global surgery indicators, such as injections and infusions). Claims must include documentation proving the E&M service is significant and separately identifiable from the procedure work. Claims lacking supporting documentation may be denied or adjusted.
Action Required
By November 30, 2026: (1) Billing team must update billing system rules to require modifier 25 on all E&M claims paired with XXX procedures for Ohio Medicaid Anthem plans. (2) Providers must update documentation templates and encounter forms to capture evidence that E&M services are significant and separately identifiable—including that the E&M work is distinct from procedure work and does not include staff supervision or result interpretation. (3) Training team must educate providers on modifier 25 requirements and documentation standards. (4) Implement pre-claim validation to flag missing modifier 25 on dual-billed claims before submission. Failure to comply will result in claim denials, adjustments, or post-payment recoupment.