Medicare AdvantageDocumentationHigh impact
[New York] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·NY·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Medicare Advantage plans in New York will require modifier 25 on all claims billing XXX procedures with E&M services. Starting July 1, 2026, claims will be audited to verify the E&M service is significant and separately identifiable from the procedure work. Claims without proper modifier 25 or supporting documentation may be denied or subject to post-payment review.
Action Required
By May 1, 2026: Billing team must update claim submission processes to automatically append modifier 25 to all XXX procedures billed with E&M services on Medicare Advantage claims. By July 1, 2026: Providers and clinical staff must ensure documentation clearly demonstrates the E&M service is significant and separately identifiable—specifically noting work distinct from the procedure, excluding any supervision of staff or result interpretation. Update EMR templates and encounter forms to include checkboxes or documentation prompts for separate E&M justification. Train billing staff to flag and review claims that combine XXX procedures with E&M services before submission. Failure to use modifier 25 or provide supporting documentation will result in claim denials or post-payment recoupment.