Upcoming Fee Schedule Changes to Anthem Blue Cross & Blue Shield Fee Schedule for Pathology

April 25, 2019

Over the last several months, Anthem Blue Cross Blue Shield has been actively engaged in the notification process and eventual changing of their fee schedules in a number of states.  Most recently, Alaska, Missouri, Ohio, California and soon, Indiana, have or will have experienced these fee schedule changes.  The new fee schedule reimburses many pathology service codes at a rate of approximately 50% of the CMS 2019 fee schedule.  This significant rate reduction affects many, if not all, of Anthem’s commercial products and the Medicare related products.  In Ohio, this fee change will impact the following product lines: Blue Traditional, Blue Access, Blue Preferred, Blue Priority, Exchange PPO, Exchange HMO, Pathway Group HMO and Medicare Advantage. 

In addition, the new fee schedule will impact the following:
• CPT codes in the 80000 – 89000 series will be modified to reflect the rates currently in place for dedicated laboratory service providers. Certain in-office testing will be exempt from the changes.
• Rates for 0362T and 0373T will be reduced to be consistent with the recent changes to the codes definitions reducing the time per unit from 30 minutes to 15 minutes.
• Rate for 97153 will be reduced to reflect an update to the manner in which adaptive behavior services may be billed.

Anthem conducts business in the states of Ohio, Indiana, Kentucky, California, Colorado, Connecticut, Georgia, Maine, Missouri, Nevada, New York, New Hampshire, Virginia and Wisconsin.  It appears that the states are on different timelines for the implementation of this new fee schedule.  Since this is not announced in advance, it’s advised to keep your eyes out for the “material change” notice that is required to be sent announcing the new fee schedule.

APS will continue to monitor and work with this situation and will provide updates as they become available.