Medicare AdvantageDocumentationMedium impact
[Georgia] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·GA·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross Blue Shield (Georgia) will enforce modifier 25 requirements for XXX procedures billed with E&M services on Medicare Advantage plans. Claims must include modifier 25 to indicate the E&M service is significant and separately identifiable from the procedure work, or they may be denied or subject to post-payment review.
Action Required
By June 30, 2026: Billing team must implement the following changes for all Georgia Medicare Advantage claims: (1) Update billing system to require modifier 25 when E&M services are billed with XXX procedures; (2) Configure system rules to flag claims lacking modifier 25 for manual review before submission; (3) Educate providers and clinical staff on modifier 25 documentation requirements, emphasizing that the E&M service must be significant, separately identifiable, and NOT include procedure work or staff supervision/result interpretation; (4) Update encounter templates and claim submission checklists to remind providers to document the distinct nature of the E&M service. Effective May 1, 2026, claims processed without modifier 25 will be subject to denial or post-payment recovery. Failure to comply will result in claim denials and revenue loss.