Anthem's original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers. The policy was to go into effect March 1, 2018, however, due to strong opposition from the American Medical Association and other groups Anthem decided it was not in the best interest between payers and providers.
The reductions were to include the following states; California, Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin. Notification will be sent out to providers this week.
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The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...