Medicare AdvantageCoverageHigh impact
[Ohio] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·OH·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage plans in Ohio will no longer reimburse CPT 99211 (established patient office visit, minimal complexity) when billed with modifier 25. This change restricts the ability to bill separately for minor E/M services on the same day as procedures, affecting common same-day visit scenarios.
Action Required
By March 31, 2026: Billing team must implement system edits to prevent submission of CPT 99211 with modifier 25 for Anthem Medicare Advantage Ohio claims. Update encounter templates and provider documentation guidelines to clarify that 99211 cannot be separately reimbursed with modifier 25 on same-day procedures. Educate providers to use higher-level E/M codes (99212+) if a significant, separately identifiable visit occurs with a procedure. Implement claim denial monitoring starting April 1, 2026 to identify and rework any 99211-25 combinations submitted to Anthem. Failure to comply will result in claim denials and revenue loss on affected encounters.