MedicaidBilling CodesHigh impact
[New York] Use modifier 25 when billing eligible E&M services with XXX procedures
Anthem BCBS·NY·Claims & Billing
Effective date
Oct 1, 2026
We identified it
Aug 25, 2026
Summary
Effective October 1, 2026, Anthem New York Medicaid now requires modifier 25 on all E&M services billed with XXX procedures (procedures with global surgery indicators, such as injections and infusions). 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 September 1, 2026: Billing team must update billing software to automatically append modifier 25 to all E&M service codes when billed with XXX procedures on Anthem New York Medicaid claims. Providers must begin documenting that E&M services are significant and separately identifiable from the procedure (not bundled work and not supervision/interpretation). Beginning December 1, 2026, documentation review will occur; prepare to submit medical records showing the E&M service addresses a separate condition or requires distinct evaluation work. Claims processed on or after October 1, 2026 without modifier 25 will be denied. Claims processed on or after December 1, 2026 without adequate documentation supporting distinct E&M work may be subject to post-payment recovery or adjustment.