Medicare AdvantageCoverageMedium impact
[California] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·CA·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage in California will no longer reimburse CPT code 99211 (established patient office visit, minimal complexity) when billed with modifier 25. This change affects billing practices for E/M services provided on the same day as procedures. Practices must stop billing 99211 with modifier 25 to Anthem MA plans in California or face claim denials.
Action Required
By March 31, 2026: Billing team must update claim scrubbing rules in the billing system to prevent submission of CPT 99211 with modifier 25 to Anthem Medicare Advantage plans in California. Providers must review encounter documentation and workflows to ensure 99211 is not billed with modifier 25 going forward; if a significant E/M service occurs on the same day as a procedure, use CPT 99212 or higher instead. Update provider education materials and internal billing guidelines to clarify this restriction is Anthem MA-specific. Flag any pending claims with 99211+25 combination for Anthem MA in CA for manual review and correction before April 1, 2026. Failure to comply will result in claim denials and rework.