Description

A modifier enables a provider to report that a service or procedure has been altered by some specific circumstance when that circumstance is not defined by a different code. The use of modifiers eliminates the need for separate procedure listings that may describe the modifying circumstances. Modifiers may be used to indicate that:

• A service or procedure has a professional or technical component. 
• A service or procedure was performed by more than one physician and/or in more than one location. 
• A service or procedure has been increased or reduced.
• Only part of a service was performed. 
• An add-on or additional service was performed. 
• A bilateral procedure was performed. 
• A service or procedure was provided more than once.
• Unusual events occurred. 
• A service or procedure was performed on a specific site. 

Certain modifiers are used for informational purposes only and do not affect reimbursement.

Policy

Blue Cross NC utilizes modifiers in determining reimbursement and eligibility. Services billed with inappropriate modifiers or that lack the appropriate modifier according to this policy will not be eligible for reimbursement.

Reimbursement Guidelines

Modifiers Defined by CPT^® Appendix A 

• Modifier 22 will not affect claims processing adjudication. In general, Blue Cross Blue Shield North Carolina (Blue Cross NC) does not allow a severity adjustment to fee allowances. Payment for new technologies is based on the outcome of the treatment rather than the "technology" involved in the procedure. 
• Modifier 24 is used to report an evaluation and management service performed during a postoperative period by the same physician or same group practice for reasons unrelated to the original procedure. See “Global Surgery” reimbursement policy.
• Modifier 25 – See “Evaluation and Management Services” reimbursement policy. 
• Modifier 26 designates the professional component of a procedure. When the physician’s component is separately reportable, the service may be identified by appending modifier -26 to the procedure code. 
• Modifier 47 is used to report anesthesia by the attending or assistant surgeon. No additional benefits are allowed above the total allowed for the surgical procedure if the anesthesia services are not administered by, or under the supervision of, a doctor other than the attending surgeon or assistant surgeon. 
• Modifier 50 designates a bilateral procedure performed at the same session. Use of the 50 modifier will not result in additional reimbursement when used with procedures which cannot be performed bilaterally or for which the base CPT code signifies a bilateral procedure. 
• Modifier 51 designates multiple procedures that are performed at the same session by the same provider, other than evaluation and management services, physical medicine and rehabilitation services, or provision of supplies. Modifier 51 is not appropriate to append to evaluation and management services. This modifier is not to be appended to designated “add-on” codes. 
• Modifier 52 indicates that a service or procedure has been partially reduced or eliminated at the physician’s discretion. 
• Modifier 53 – See “Discontinued Procedures” reimbursement policy 
• Modifiers 54, 55 and 56 designate split surgical care. (see related “Split Surgical Package” reimbursement policy) 
• Modifier 57 is an evaluation and management service that results in the initial decision to perform surgery. It is intended to report that the decision to perform major surgery occurred on the day of or day prior to, a major (90-day global) surgical procedure. See “Global Surgery” reimbursement policy regarding appropriate use of Modifier 57.

Modifier 57 should not be appended to an evaluation and management service associated with a major surgery that has been planned in advance. Some categories of planned surgery would be inconsistent with a decision for surgery occurring the day of, or day prior to, the procedure, except when performed in the setting of an office or inpatient consultation, or emergency department. Categories of these planned surgeries include but are not limited to spine surgery (excluding fractures and dislocations), arthroplasty (total, partial, revision), congenital/deformity procedures, chronic/sub-acute conditions, and transplant procedures. Evaluation and management services with modifier 57 for these categories of planned surgery will be denied when billed outside the consultative and emergency settings noted above.

Evaluation and management services performed the same day as a 90-day global medical or surgical service will be denied as included in the global surgical package unless the service consisted of a decision for surgery and is indicated with modifier 57.

• Modifier 59 designates that a procedure is distinct or independent from another non-evaluation and management service performed on the same day.
  
  The Centers for Medicare & Medicaid Services (CMS) has established four HCPCS modifiers to define subsets of the 59 modifier. These modifiers function in the same manner as modifier 59. Since the HCPCS modifiers are more detailed descriptions of modifier 59, it would be incorrect to include both on the same claim line according to CMS. Therefore, any code appended with 59 in addition to XE, XS, XO, or XU will not be eligible for reimbursement.
  • XE separate encounter. A service that is distinct because it occurred during a separate encounter. 
  • XS separate structure. A service that is distinct because it was performed on a separate organ/structure. 
  • XP separate practitioner. A service that is distinct because it was performed by a different practitioner.
  • XU unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service.
• Modifiers 62 and 66 designate services performed by two surgeons or a surgical team, and will be reviewed on an individual consideration basis. See “Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines” reimbursement policy. 
• Modifier 73 – See “Discontinued Procedures” reimbursement policy. 
• Modifier 78 – See “Unplanned Return to Surgery” reimbursement policy. 
• Repeat Procedures, Unplanned Return to the Operating Room, and Unrelated Procedures. See also “Global Surgery” reimbursement policy.
  • A procedure code billed with modifier 76 will not be eligible for reimbursement unless Blue Cross NC has received a claim indicating that the same provider using the same provider ID also performed that same service on the same date or within the post operative period.
  • Similarly, a procedure code billed with modifier 77 will not be eligible for reimbursement unless Blue Cross NC has also received a claim indicating that a different provider using a separate provider ID has also performed that same service on the same date as the original service or within the post operative period. 
  • In order for a procedure code billed with modifier 78 or 79 to be eligible for reimbursement, Blue Cross NC must have evidence that a procedure was billed on the same date of service or within the post operative period as defined by the 0, 10, or 90 day post operative period definition.
  • Modifier 90 represents a reference (outside) laboratory and will only be eligible for reimbursement if billed by a provider with a specialty designation of Laboratory or Pathology. 
  • Modifier 92 is used for alternative laboratory platform testing. Only HIV testing will be eligible for reimbursement when billed. All other codes containing this modifier will not be eligible for reimbursement. See also “Pathology Billing Guidelines” medical policy.
  • Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.
  • Modifier Use in Fracture Care

When a fracture or dislocation care code is billed in the office setting and the same code has been billed by any provider in the past 10 days, it is assumed that the second billing of this code is duplicative, and it will be denied. When a fracture care code is billed in the office setting that is different from another fracture care code that was billed in the previous 2 weeks, it is assumed that the second code was inappropriately coded and that it also represents post-operative care for the earlier service. In this situation, the second code will be denied. An exception exists for procedures billed with an appropriate modifier which designates that the services are unrelated. The modifiers are listed below: 

• 55 (Post-operative management only) 
• 76 (Repeat procedure by same physician) 
• 77 (Repeat procedure by another physician) 
• 78 (Return to operating room for a related procedure during the post-operative period) 
• 79 (Unrelated procedure or service by same physician during the post-operative period) 

Modifier 54 (surgical care only) is not appropriate to use with fracture care codes for closed treatment without manipulation in the emergency department.

Level II HCPCS/National Modifiers

• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross NC uses CMS as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife. 
• Modifier AX – item furnished in conjunction with dialysis services. Drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier. 
• Anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”).
• Erythropoiesis stimulating agent (ESA) treatment requires modifier usage; to include EA, EB, or EC. 
  • Modifier EA - Erythropoietic stimulating agent (ESA) administered to treat anemia due to anticancer chemotherapy. 
  • Modifier EB - Erythropoietic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy. 
  • Modifier EC - Erythropoietic stimulating agent (ESA) administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy. 
• Modifier GQ designates services performed via asynchronous telecommunications system. Refer to Telehealth Reimbursement Policy. 
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be reimbursed with codes specified in the reimbursement policy titled, “Telehealth.” 
• Modifier MS - six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty. 
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to reimbursement policy titled “Nonpayment for Serious Adverse Events”. 

Modifier PI - Positron emission tomography (PET) or PET/computed tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing. Initial PET services reported for oncology are only eligible for reimbursement when submitted with Modifier PI.

• Modifier RA – Replacement of a DME item. 
• Modifier SL- State supplied vaccine. Vaccines and toxoids provided at no cost by the state are not eligible for reimbursement. However, the administration of such vaccines and toxoids may be eligible for reimbursement. See “Immunization Guidelines” reimbursement policy. 
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. . See “Rehabilitative Therapies” medical policy.
• Modifier RB – Replacement of a part of DME furnished as part of a repair 
• Modifier TC designates the technical component of a service. When the technical component is separately reportable, the service may be identified by appending modifier TC to the procedure code.
• X-Ray Transportation (UN, UP, UQ, UR, or US) 
  • Set up of portable X-Ray equipment (Q0092) is only eligible for reimbursement when transportation of portable x-ray equipment (R0070 or R0075) has also been billed and paid for on the same date of service.

• Combined Diagnostic and Screening Mammography Performed on the Same Date
  
  Consistent with CMS policy, specific modifiers are required when both a screening and diagnostic mammogram are performed on the same date of service. In this scenario, the diagnostic mammogram must be appended with Modifier GG in order to be eligible for reimbursement. Similarly, the screening mammogram must also be appended with Modifier 59, XE, XP, or XU otherwise, the screening mammogram will not be eligible for reimbursement. 
• Anesthesia Modifiers
  
  Physicians must report appropriate anesthesia modifiers with general anesthesia services to denote whether the service was personally performed, medically directed, medically supervised, or represented monitored anesthesia care. Also, services rendered by CRNAs must report the appropriate anesthesia modifier to indicate whether the service was performed with or without medical direction by a physician. Appropriate modifiers for anesthesia services are: AA, AD, G8, G9, QK, QS, QX, QY, and QZ General anesthesia services (CPT 00100-01969)* will be denied if billed without an appropriate modifier. Anesthesia modifiers should only be appended to anesthesia services. Additional service modifiers may be appropriate to use for anesthesia services, however when inappropriate service modifiers are appended to an anesthesia code, that service will not be eligible for reimbursement. (See also medical policy titled, “Anesthesia Services” and reimbursement policy titled “Anesthesia, Professional and Facility”). *01960 and 01967 are considered non-timed procedures and therefore do not require a modifier.
• Deceased Modifiers 
  
  Services, supplies and/or devices are not reimbursable if modifier CA, PM, P6 or QL has been reported on a prior date of service.
• Professional and Technical Components
  
  Blue Cross utilizes CMS National Physician Fee Schedule (NPFS) Relative Value File, Professional Component (PC) and Technical Component (TC). Please reference the following table: 

Although CMS does not advise on all codes, Blue Cross NC reserves the right to enforce professional and technical components as deemed appropriate.

Technical components and Technical component only codes are not eligible for reimbursement in the outpatient or inpatient facility setting on a professional claim form.

At times, it may be necessary to transport x-ray equipment to the location of the member, such as the member’s home or even an assisted living or nursing facility where the member resides, so that the x-ray service can be completed. In that case, the applicable revenue code for the transportation of the equipment will be required.

Global Only codes are those codes that represent the global service for which there are separate codes that represent the technical and professional components. These codes are not to be appended with Modifiers 26 or TC. Blue Cross NC will not provide reimbursement for Global Only codes with Modifiers 26 or TC. Blue Cross NC will not reimburse physicians for services with a PC/TC Indicator 4, when rendered in a facility setting.

Rationale

Claims with inappropriate modifier to procedure code combinations will be denied. Claims must be resubmitted with correct modifier for payment. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

Reimbursement for a procedure code/modifier combination will be considered only when the modifier has been used appropriately in accordance with correct coding principles defined ICD-10, HCPCS and CPT.

Related policy

Anesthesia, Professional and Facility

Anesthesia Services (medical policy)

Bundling Guidelines

Co-Surgeon, Assistant Surgeon, Team Surgeon, and Assistant-at-Surgery

Discontinued Procedures

Immunization Guidelines 

Maximum Units of Service

Multiple Surgical Procedure Guidelines for Professional Providers

Nonpayment for Serious Adverse Events

Radiation Therapy Services

Radiology Services

Rehabilitative Therapies (medical policy)

Split Surgical Package

Telehealth Policy

Unplanned Return to Surgery

References

Medical Policy Advisory Group - 10/2003

Medical Policy Advisory Group - 03/10/2005

Senior Medical Director – 3/2011

Medical Director review – 1/2012

Medical Director review – 12/2013

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

Medical Director review – 12/2014

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R1999OTN.pdf

Centers for Medicare & Medicaid Services, CMS Manual System, and Medicare Claims Processing Manual 100-04

American Medical Association, Current Procedural Terminology (CPT ^®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

Healthcare Common Procedure Coding System 

History 

1/00 Implementation

1/00 Revised to correct billing guideline for modifier -50.

3/00 Removed Blue Edge reference.

8/00 Clarification that -59 modifier will affect claims processing for Blue Care, Blue Choice, Blue Options, and Classic Blue in the ’When it is covered’ and ’When it is not covered’ sections.

01/02 Updated information pertaining to the place of service for a -25 modifier. Section added to indicate when a -25 modifier is not covered. Added information pertaining to the -57 modifier in both the covered and non-covered sections.

05/03 Added modifier - MS and -RP in the ’When it is covered’ section.

10/03 Medical Policy Advisory Group review - 10/2003.

02/04 This policy applies to Blue Care, Blue Choice, Blue Options, and Classic Blue products only. Clarified this point in the policy. Statement removed from modifier -59 explanation.

4/07/05 Medical Policy Advisory Group reviewed policy on 03/10/2005. Medpoint and PCP removed from this policy. Corrected typos.

3/16/06 Renamed sections “When it is covered” and “When it is not covered” to read “When a modifier may be covered” and “When a modified may not be covered.” Added the policy number to Key Words section. Added the following statement “Blue Cross and Blue Shield of North Carolina uses the American College of Surgeons as its primary source for determining those procedures available for assistant surgeon benefits to Modifier -80, -81, -82 and AS. Modifier -21 removed from policy. .Statement that applied to PPO/CMM was removed from modifier -59.

5/8/06 Added statement to the section "When a modifier may not be covered" to read: Modifier -22 will not affect claims processing adjudication. In general, BCBSNC does not allow a severity adjustment to fee allowances. Payment for new technologies is based on the outcome of the treatment rather than the "technology" involved in the procedure. Added policy number to Key Words section. Medical Policy Advisory Group review 3/24/06 including revisions noted above. No additional changes required to policy criteria.

10/16/06 In the section "When a Modifier may be covered" revised procedure(s) to service(s) pertaining to Modifier -25. Statement added "The - 25 modifier will not be recognized with a minimal office visit for an established patient (99211) performed on the same date as a preventative medicine visit (99391 - 99397)." Removed the statement "Modifier - 25 is not recognized for an separate E&M service performed on the same date as a preventive medicine visit." in the section "When a Modifier may not be covered."

9/10/07 Modifier GT - Via interactive audio and video telecommunication systems will be allowed with code 99201 - 99205, 99212 - 99215(Office or Other Outpatient Services) and 99241 - 99245 (Office or Other Outpatient Consultations) added to “When a Modifier may be covered”. Modifier GQ - Via asynchronous telecommunications system will not be allowed specifically with code 99201 - 99215(Office or Other Outpatient Services) and 99241 - 99245(Office or Other Outpatient Consultations) and Modifier GT - will not be recognized with a minimal office visit for an established patient (99211) added to “When a modifier may not be covered”. Modifier GT - will not be recognized with a minimal office visit for an established patient (99211) added to “When a modifier may not be covered.” Added to Policy Guidelines: BCBSNC does not reimburse for evaluation and management and consultation services provided via telephone, Internet, or other communication network or devices that do not involve direct, in-person patient contact. Revised wording related to modifier 57 from “Modifier - 57 designates the decision to do surgery. It is accepted only with inpatient and observation E&M codes when the decision is made to do a major surgical procedure. A major surgical procedure is defined as one with a 90 day global period. The global period starts the day prior to surgery. The modifier is appropriate to signify that the decision was made to do a major surgery procedure within the global period.” to “Modifier 57 - is an evaluation and management service that results in the initial decision to perform surgery.” from “When a modifier may be covered.” Statement “Modifier -57 will not be recognized with any E&M code other than inpatient or observation” removed from “When a modifier may not be covered”. Medical Policy reviewed 08/17/07 by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

12/03/07 Reference added to clarify that “Blue Advantage” applies to this policy. Statement, “Modifier -25 will not be recognized with inpatient E&M services.” removed from “When a Modifier may not be covered”.

07/20/09 Added modifier -54, -55, and -56 to “When a Modifier may be covered.” Removed references related to American College of Surgeons. Added nurse practitioner and nurse midwives to modifier “AS”. New modifiers PA, PB and PC are effective 7/1/2009, which describe serious adverse events. Removed references to Blue Advantage, Blue Care, Blue Choice, Blue Options, and Classic Blue Products Policy reviewed by VP/ Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

6/22/10 Policy Number(s) removed (amw)

09/14/10 Removed “BCBSNC does not reimburse for evaluation and management and consultation services provided via telephone, Internet, or other communication network or devices that do not involve direct, in-person patient contact.” Added modifier -52, -RA and –RB and deleted modifier RP. Policy reviewed by VP/ Senior Medical Director, Healthcare Quality.

3/15/11 Added Modifier -59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 and when performed in conjunction with 22630 and 22632. Lumbar laminectomy, facetectomy and foraminotomy procedures are typically considered incidental to the lumbar arthrodesis, posterior interbody technique; and therefore are not eligible for separate reimbursement. Changes to policy reviewed by Senior Medical Director 3/10/2011. Notification given 3/15/2011. Policy effective 6/19/2011. Added “same group practice” to modifier 24.(dpe) 

06/07/11 Further clarification of Modifier -59; added the following statements: “Based on the most common clinical scenario, it is expected that when a lumbar laminectomy, facetectomy, and/or foraminotomy is billed with a posterior lumbar interbody fusion, the procedures are being performed on the same level. In the unusual clinical circumstance when the procedures are performed at different vertebral levels, clinical information will be required to be submitted on appeal.” (dpe)

3/6/12 Revised the definitions of the modifiers. The sections formerly titled “when a modifier may be covered” and “when modifiers may not be covered” were combined into one section titled “when a modifier may affect claims payment.” Information added to the Policy Guidelines section regarding fracture care codes and anesthesia modifiers. (adn)

12/10/13 In the “Policy” section, deleted modifier 22 from the list of modifiers that may affect claims payment. In the “Modifier Guidelines” section, bulleted section on Modifier 59: added codes 22633 and 22634 so that the statement reads: “Modifier 59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 when performed in conjunction with 22630, 22632, 22633 and/or 22634.” Statement regarding anatomic-specific modifiers was reworded and modifiers LM and RI added to the list of coronary artery anatomic modifiers. In the “Policy Guidelines” section: deleted the statement “BCBSNC claims system processes only one modifier per CPT code.” Notification given 12/10/13 for effective date 2/11/14. (adn)

5/13/14 Policy category changed from “Corporate Medical Policy” to “Corporate Reimbursement Policy”. No changes to policy content. (adn)

12/30/14 The Centers for Medicare & Medicaid Services (CMS) has established four HCPCS modifiers to define subsets of the -59 modifier. Modifiers XE, XS, XP, and XU added to the -59 modifier section. BCBSNC will continue to recognize the -59 modifier. The CMS modifiers (XE, XS, XP, XU) are considered informational only. (adn)

7/28/15 Added “AJ, P3, P4, P5, QW, SH, SJ” to list of HCPCS modifiers that may affect claims payment. Revised Modifier GQ to read: services performed via asynchronous telecommunications system will not be allowed. Revised Modifier GT to read: services performed via interactive audio and video telecommunication systems will be allowed with codes specified in corporate reimbursement policy titled, “Telehealth.” (adn)

9/1/15 The following statement was deleted from the paragraph regarding Modifier 59: “BCBSNC will continue to recognize the 59 modifier. The CMS modifiers (XE, XS, XP, XU) are considered informational only.” (adn)

12/30/16 The following guideline added: Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”). Information added regarding modifier 95. (an)

3/31/17 Modifier 59 (or XE, XS, XP, XU) will not allow additional payment when a diagnostic endoscopic base code is submitted with a surgical endoscopic code from the same endoscopic family. The endoscopic family is defined by the Medicare Physician Fee Schedule. Notification given 3/31/2017 for policy effective date of 5/26/2017. (an)

7/28/17 Modifier 54 (surgical care only) is not appropriate to use with fracture care codes for closed treatment without manipulation in the emergency department. Notification given 7/28/2017 for policy effective date of 9/29/2017. (an)

11/28/17 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18. (an)

2/9/18 Modifier AX – item furnished in conjunction with dialysis services. J0605 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease. They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier. Notification given 2/9/2018 for policy effective date 4/13/2018. (an)

4/27/18 Correction for codes related to Modifier AX. Correct codes are J0604 and J0606. (an)

12/31/18 Routine annual review. No change to current policy. (an)

4/30/19 Corrected typo. Modifier “SP” changed to “XP” throughout. (an) 1/14/20 Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement. (an)

11/24/20 Policy guidelines updated with “*01960 and 01967 are considered non-timed procedures and therefore do not require a modifier.” No change to policy statement. (eel)

12/31/20 Routine policy review. Medical Director approved 12/2020. No changes to policy statement. Deleted code 99201 removed. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel)  

6/1/21 Updated modifier 25 to redirect to Evaluation and Management Services policy. (eel)

12/30/21 Routine policy review. Modifiers 53, 73, and 78 added to policy statement. Added related policies for Split Surgical Package, Discontinued Procedures, and Unplanned Return to Surgery. Medical Director approved. (eel)

6/1/22 Policy language updated throughout. Policy section restated as Blue Cross NC utilizes modifiers in determining reimbursement and eligibility. Services billed with inappropriate modifiers or that lack the appropriate modifier according to this policy will not be eligible for reimbursement. Reimbursement Guidelines updated with instructions for Modifier 59, Repeat or Unplanned Procedures, Modifier 90, Modifier 92, Modifier SL, Combined Mammography, Anesthesia Modifiers, and Professional and Technica Components. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine Policy Review. Added “Refer to Telehealth Policy” under Modifier GQ description. Added link to Telehealth Policy under Related Policies. (cjw)

5/2/2023 Clarification to AX modifier, coding update. Notification on 3/1/2023 for effective 5/2/2023. (cjw)

9/28/2023 Added Erythropoiesis stimulating agent (ESA) modifiers, deceased modifiers, Modifier PI, and X-Ray Transportation. Medical Director Approved. Notification on 7/18/2023 for effective date 9/28/2023. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy. 

Legal

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.

BLUE CROSS^®, BLUE SHIELD^® and the Cross and Shield symbols are marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and trade names are the property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association