Medicare AdvantageAdministrativeHigh impact
[Ohio] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·OH·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) will enforce modifier 25 requirements for E&M services billed with XXX procedures on Medicare Advantage plans. Starting July 1, 2026, claims will be reviewed to verify the E&M service is significant and separately identifiable from the procedure work. Billing teams must ensure proper modifier 25 use and supporting documentation to avoid claim denials or post-payment reviews.
Action Required
By May 1, 2026: Billing team must update all billing system edits and claim submission templates to require modifier 25 when billing E&M services with XXX procedures for Medicare Advantage patients in Ohio. Providers must document that the E&M service is significant and separately identifiable—not duplicating procedure work or including result interpretation/staff supervision. By July 1, 2026: Implement additional claim review procedures to ensure documentation supports distinct E&M services. Train clinical and billing staff on modifier 25 requirements and documentation standards. Update encounter templates to remind providers to document the separate E&M work. Failure to use modifier 25 or provide supporting documentation will result in claim denials or post-payment recoupment.