Blue Cross Blue Shield Modifier 25 Reimbursement Update

KZA Coding Alert | Billing and Reimbursement

PAYER: Blue Cross Blue Shield of Michigan (BCBSM) & Blue Care Network (BCN)

EFFECTIVE DATE: May 1, 2026

IMPACT: E/M services billed with Modifier 25 reimbursed at 50% of contracted rate

What Is Changing?

Beginning May 1, 2026, BCBS of Michigan and Blue Cross Network (BCN) will reduce reimbursement for Evaluation & Management (E/M) services billed with Modifier 25 when performed on the same calendar date as a minor procedure by the same provider for the same patient.

Reimbursement Rate

50% of the contracted rate ⚠️

100% of contracted rate ✓

Service

E/M with Modifier 25 (same day as minor procedure)

Minor procedure

Plans Affected

This policy applies to commercial and Medicare Advantage products, including:

• BCBSM Commercial

• BCN Commercial

• Medicare Plus Blue℠

• BCN Advantage℠

• Federal Employee Program®

Criteria for Using Modifier 25

Modifier 25 may be used only when ALL of the following apply:

• The patient's condition requires a significant, separately identifiable E/M service beyond the usual pre-/post-operative care

• The E/M and minor procedure occur on the same date, by the same provider, for the same patient

• The procedure has a 0- or 10-day global period (minor procedure)

Applicable E/M Codes:

• 99202–99205 (new patient office/outpatient visits)

• 99212–99215 (established patient office/outpatient visits)

Exclusions — 50% Reduction Does NOT Apply To:

Details

E/M visit within 1 calendar day after an ER visit (billed with modifier 25). ER claim must process first.

Global indicator XXX or “does not apply.” Examples include:

• Vaccine administration

• Chemotherapy

• ECGs, pulmonary function tests, radiology, and laboratory services

Use Modifier 57 (not 25) when the E/M leads to a decision for a major surgical procedure.

Exclusion

Post-ER E/M Visit

Non-Surgical Procedures (No Global Period)

Major Procedures (90-Day Global)

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⚠️  Audit Risk — Action Required

Modifier 25 claims may be subject to medical record review and post-payment audit. Ensure your documentation clearly supports:

• A significant, separately identifiable E/M service was performed

• The E/M was beyond the usual pre-/post-operative care for the procedure

• Medical necessity is clearly documented in the patient record

📄  Reminder: Preventive Services Policy (Effective June 1, 2024)

E/M services billed on the same date as a preventive service are also reimbursed at 50% of the allowed amount under an existing separate policy.

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Recommended Action Steps

• Review your current billing workflows for same-day E/M + minor procedure encounters

• Educate providers and coding staff on updated reimbursement rates effective May 1, 2026

• Audit recent claims where Modifier 25 was used to identify documentation gaps

• Confirm Modifier 57 is being used (not 25) when the E/M leads to a major surgical procedure

• Access the full Modifier 25 Reimbursement Policy at https://providerinfo.bcbsm.com/documents/alerts/2026/202602/alert-20260226-clarification-policy-update-em-codes-modifier-25.pdf.

This alert is for informational purposes only. Always refer to the official medical policy details.

Contact Us at KZAnow.com or 312-642-5616 to schedule your annual audit today!