MedicaidAdministrativeHigh impact
[California] Use modifier 25 when billing eligible E&M services with XXX procedures
Anthem BCBS·CA·Claims & Billing
Effective date
Oct 1, 2026
We identified it
Aug 25, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross Medi-Cal Managed Care now requires modifier 25 on all E&M services billed with XXX procedures (injections, infusions, non-physician procedures with global surgery indicators). Beginning December 1, 2026, claims with modifier 25 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 30, 2026: Billing team must update billing system and encounter templates to automatically append modifier 25 to E&M codes (99201-99215 range) when billed alongside XXX procedures on Anthem Medi-Cal claims. Providers must be trained that modifier 25 requires E&M documentation demonstrating: (1) service may address same condition as procedure but is distinct, (2) documentation does not duplicate procedure work, and (3) no staff supervision or result interpretation is included in the E&M charge. By November 30, 2026: Audit a sample of modifier 25 claims to ensure compliant documentation is present in medical records. Starting December 1, 2026: All modifier 25 claims will undergo documentation review by Anthem; insufficient documentation supporting a distinct E&M service will result in claim denial, adjustment, or post-payment recoupment. Failure to comply will increase claim rejection rates and revenue loss.