CurrentAnthemPolicy G-06011

Modifier 24

This document governs Anthem Blue Cross reimbursement for Evaluation and Management (E/M) services billed with modifier 24 when performed during the postoperative period and unrelated to the original procedure; it applies to providers submitting claims to Anthem (California Medicare Advantage context).

Policy Summary

PayerAnthem

PolicyModifier 24 reimbursement for postoperative E/M services

Policy CodePolicy G-06011

Change TypeOperational wording update

Effective DateJun 11, 2025

Next Review Date

Key ActionEnsure billing includes the appropriate level E/M with modifier 24, an unrelated diagnosis code, and clear documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

06/11/2025 Review approved and effective: removed limited from Policy section.

10/14/2024 Review approved and effective: updated Definitions section.

12/27/2022 Title updated and minor language/format changes.

100%reimbursement rate

3required criteria

CAjurisdiction

5history entries

Modifier 24 Coverage Criteria

Modifier 24 coverage criteria

Reimbursement allowed when ALL of the following are met:

ALL of the following

ALL of the following
- The appropriate level of E/M service is billed and appended with modifier 24
- A diagnosis code unrelated to the original procedure is indicated for the E/M service
- The reason for the E/M service is clearly documented in the member's medical record
Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate for the E/M service performed during the postoperative period of the original procedure

Policy Summary

PayerAnthem

PolicyModifier 24 reimbursement for postoperative E/M services

Policy CodePolicy G-06011

Change TypeOperational wording update

Effective DateJun 11, 2025

Next Review Date

Key ActionEnsure billing includes the appropriate level E/M with modifier 24, an unrelated diagnosis code, and clear documentation to support medical necessity.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Codes and Documentation

ModifiersModifierCovered

Modifier 24

Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

Required documentation elements

E/M level and modifierThe appropriate level of E/M service must be billed and appended with modifier 24

Unrelated diagnosisA diagnosis code unrelated to the original procedure must be indicated for the E/M service

Clinical documentationThe reason for the E/M service must be clearly documented in the member's medical record

Consequences of incorrect useFailure to use modifier 24 correctly may result in denial and/or recoupment of claim payments

Billing and Authorization Considerations

Billing Rule

Billing and Authorization Considerations

Ensure that you use proper billing and submission guidelines, including industry-standard, compliant codes on all claim submissions. Services should be billed with Current Procedural Terminology (CPT®) codes, Healthcare Common Procedure Coding System (HCPCS) codes, and/or revenue codes. These codes must be fully supported in the medical record and/or office notes. Reimbursement policies apply to both participating and non-participating professional providers and facilities unless otherwise noted. If appropriate coding/billing guidelines or current reimbursement policies are not followed, we may reject or deny the claim, recover and/or recoup claim payment, or adjust the reimbursement to reflect the appropriate services and/or procedures performed.

Prior authorization and medical necessity requirements must be met where applicable; services must meet authorization guidelines appropriate to the procedure, diagnosis, and the member's state of residence.
Bill E/M services performed during a postoperative period with modifier 24 when unrelated to the original procedure.
When billing with modifier 24: the appropriate level of E/M service must be billed and appended with modifier 24; a diagnosis code unrelated to the original procedure must be indicated; and the reason for the E/M service must be clearly documented in the member's medical record.
Failure to use modifier 24 correctly may result in denial of the E/M service and/or recoupment of claim payments.
Ensure documentation in the medical record supports the codes billed; inadequate documentation can lead to claim denial or recovery.

OpenPayer

Modifier 24

Modifier 24 Coverage Criteria

Codes and Documentation

Billing and Authorization Considerations

Key Definitions