Medicare AdvantageCoverageHigh impact
[Virginia] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·VA·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Blue Cross Blue Shield (Virginia) will no longer reimburse CPT code 99211 when billed with modifier 25. This impacts billing strategies for low-level E/M services performed on the same day as procedures. Practices must stop billing 99211 with modifier 25 to avoid claim denials and ensure proper code selection for separate E/M reimbursement.
Action Required
By March 31, 2026: Billing team must update billing software and claim scrubbing rules to prevent submission of CPT 99211 with modifier 25 for Anthem Virginia Medicare Advantage plans. Implement automated edit to deny or alert on this code-modifier combination before claim submission. Providers must be notified in writing of this change and trained to document higher-level E/M codes (99212-99215) when a significant, separately identifiable evaluation and management service is provided on the same day as a procedure. Update encounter templates and superbills to reflect this restriction. Prior to April 1, 2026, audit recent claims history for 99211+modifier 25 combinations and develop resubmission strategy for any recently denied claims. Failure to comply will result in automatic claim denials and potential overpayment recovery.