By Jan Hailey, MHL, CMC, CMCO, CMIS, CMOM, CMCA-E/M

Beginning April 1, 2025, Anthem implemented a prepayment coding validation review process for outpatient claims submitted with the following modifiers: 24, 25, 58, 59, 78, 79, E1–E4, F1–F9, TA, LT, RT, LC, LD, RC, LM, RI, XE, XP, XS, and XU.

Anthem states this enhancement is designed to ensure compliance with published reimbursement policies and the National Correct Coding Initiative (NCCI) guidelines, which mandate the appropriate use and submission of modifiers. As part of this review, the application of modifiers will be assessed in relation to the edits they are intended to bypass, including those established by the NCCI.

Claims undergoing validation, along with any associated services, will be carefully evaluated by clinical analysts, including registered nurses and certified coders, to determine whether the applied modifier appropriately overrides the edit.

For further details, refer to the March 2025 Provider Newsletter: Certain modifiers for outpatient claims will receive prepayment coding review - Provider News