Medicare AdvantageDocumentationHigh impact
[California] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·CA·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Medicare Advantage plans in California will enforce modifier 25 requirements when billing E&M services with XXX procedures. Starting July 1, 2026, claims will be audited to verify the E&M service is significant and separately identifiable from the procedure work. Claims lacking proper documentation may be denied or subject to post-payment review.
Action Required
By May 1, 2026: (1) Billing team must update billing system rules to require modifier 25 when XXX procedures are billed with E&M services for Anthem Medicare Advantage California claims. (2) Providers must be educated that modifier 25 only applies when the E&M service is significant and separately identifiable, not included in procedure work, and does not include staff supervision or result interpretation. (3) Update encounter forms/templates to prompt providers to document the distinct E&M service separately. By July 1, 2026: Ensure all supporting documentation clearly demonstrates the separate, identifiable E&M work. Failure to apply modifier 25 or provide adequate documentation will result in claim denials or post-payment recoupment.