Medicare AdvantageCoverageMedium impact
[Georgia] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·GA·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage plans in Georgia will no longer reimburse CPT code 99211 (established patient office visit, minimal complexity) when billed with modifier 25. This change restricts separate payment for minimal E/M services on the same day as other procedures, even when modifier 25 documentation supports a significant, separately identifiable service.
Action Required
By March 31, 2026: Billing team must update claim scrubbing rules in billing software to deny or reject CPT 99211 claims when modifier 25 is appended for Anthem Medicare Advantage Georgia members. Providers should review encounter templates and documentation guidelines to avoid inadvertent coding of 99211 with modifier 25; consider using CPT 99212 or higher when a significant, separately identifiable E/M service is provided on the same day as a procedure. Update internal billing guidance and provider alerts. Failure to comply will result in claim denials and possible recoupment.