Medicare AdvantageCoverageMedium impact
[New York] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·NY·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage plans in New York will no longer reimburse CPT code 99211 when billed with modifier 25. This change restricts separate payment for minimal E/M services performed on the same day as another procedure, even when modifier 25 is used to indicate a significant, separately identifiable service.
Action Required
By March 31, 2026: Billing team must update billing system edits to prevent or flag claims for CPT 99211 with modifier 25 for Anthem Medicare Advantage New York members, as these will be denied for reimbursement. Providers should review encounter documentation to identify cases where 99211 is currently billed with modifier 25 and plan alternative coding (e.g., 99212 or higher level E/M codes) when appropriate documentation supports a higher level of service. Update provider education materials and billing guidelines to communicate this change. Failure to comply will result in claim denials and potential rework.