Nov. 25, 2025
Effective March 1, 2026, we’ll enhance our claims editing and review process to monitor the proper use of Evaluation and Management coding, Oncology Drugs and Services coding, and Modifiers 25 and 59.
Learn more:
- Evaluation and Management Coding CMS - Evaluation and Management Services
- Oncology Drugs and Services Coding CMS - Approved Drugs and Biologicals
- Modifier 25: Used for a significant, separately identifiable Evaluation and Management service CMS - Evaluation and Management Services – Page 5
- Modifier 59: Used for a distinct procedural service CMS - Proper Use of Modifiers 59, XE, XP, XS & XU – Page 2
This enhancement applies to Medicare Advantage and Medicaid member claims.
What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. Claims with these modifiers used inaccurately may result in delayed or denied payment. With your help, the enhanced claims review process will help our members get the right care at the right time and in the right setting. Please note that this enhancement should not impact response times.
More information: Watch News and Updates for updates.
The information provided does not constitute coding or legal advice. Physicians and other health care providers should use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment, and to submit claims using the most appropriate code(s) based upon the medical record documentation, coding guidelines and reference materials.