Enhanced editing and modifier requirements

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will be instituting updated reimbursement policies to better align with CMS Coverage and Modifiers effective 9/18/2023.  We will be implementing enhancements to our claims processing system that reflect guidelines set forth by industry authorities and CMS in order to process claims consistently and in accordance with best practice standards.    

The updated policy includes updated language in four of our policies. These language updates include, but are not limited to:  

• Diagnosis Validity – CMS instruction for correct diagnostic coding  

• Drugs and Biologicals – Addition of JZ modifier 

• Global Surgery – Non-physician practitioners’ reimbursement for major (90 day) procedures 

• Modifier Guidelines – Addition of Erythropoiesis Stimulating Agents (ESA) and deceased modifiers. 

• Status Codes – Addition of Status Code “I” 

Important Notes   

• This policy will apply for any claims with date of service 9/18/2023 

• This policy will not affect your reimbursement / payment amounts. Reimbursable services will be paid at the same rates as they previously were.    

• These policies will apply to professional and facility claims unless otherwise stated. There are no changes to any processes, customer service and support, or grievances and appeals. 

Reimbursement policy notifications were communicated here for Commercial and Medicare.   

This communication applies to State Health Plan (SHP), Administrative Services Only (ASO), Fully Insured, Senior Market Administration (SMA), and IPP Host. It does not apply to FEP or IPP Home claims.