CurrentAnthemPolicy G-06015

Modifier 63 (neonate/infant surgical reimbursement)

Defines Anthem's reimbursement rules for use of CPT modifier 63 for surgeries on neonates and infants up to a present body weight of 4 kg for Wisconsin BadgerCare Plus and Medicaid SSI Programs.

Policy Summary

PayerAnthem

PolicyModifier 63 (neonate/infant surgical reimbursement)

Policy CodePolicy G-06015

Change TypeNo material changes in most recent review

Effective Date08/28/2020

Next Review Date

Key ActionDocument the neonate's present body weight in the operative report when billing modifier 63 and ensure services meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

09/06/2024, Review approved: no changes.

11/04/2022, Review approved and effective: updated minor language; updated title to only include modifier 63; updated Definitions section.

08/28/2020, Review approved and effective: updated policy language, References and Research Materials, and Definitions sections.

4 kgweight threshold

100%reimbursement basis

9/06/2024last approval

G-06015policy id

When Modifier 63 Is Reimbursed

Coverage criteria for Modifier 63

Anthem allows reimbursement when modifier 63 is valid and documented as described; specifies nonreimbursable uses.

ALL of the following

Modifier 63 must be billed on the procedure
Neonate/infant present body weight must be documented clearly in the operative report
Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate when modifier 63 is valid

Not reimbursable when billed in the following circumstances

Billed for facility services

Policy Summary

PayerAnthem

PolicyModifier 63 (neonate/infant surgical reimbursement)

Policy CodePolicy G-06015

Change TypeNo material changes in most recent review

Effective Date08/28/2020

Next Review Date

Key ActionDocument the neonate's present body weight in the operative report when billing modifier 63 and ensure services meet authorization and medical necessity guidelines.

SourceLink

On This Page

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Billed with Evaluation and Management (E/M) codes

Billed with anesthesia codes

Billed with radiology codes

Billed with pathology/laboratory codes

Billed with medicine codes (other than those appropriate for the modifier)

Billed with modifier 63-exempt codes

Billed in addition to modifier 22 (unusual services) for the same procedure code(s)

Billed with codes denoting invasive procedures that already include neonate or infant in the description

Billing and fee adjustment rules

When an assistant surgeon is used and/or multiple procedures are performed on neonates/infants < 4 kg in the same operative session, assistant surgeon and multiple procedure fee reductions apply

Operational expectations

Services billed with modifier 63 must meet authorization and medical necessity requirements per applicable program rules
Follow proper coding and submission guidelines when reporting modifier 63

Weight threshold

Applies to neonates and infants up to a present body weight of 4 kg

Codes and Thresholds

ModifiersmixedCovered

modifier 63

Reportable modifier for procedures on neonates/infants up to 4 kg

inv-03: weight threshold

Weight threshold for modifier 63 applicability4 kg

Reimbursement basis when modifier valid100% of applicable fee schedule or contracted/negotiated rate

Documentation requirementNeonate's present body weight must be documented clearly in the operative report

Documentation, Authorization, and Billing Rules

Documentation Required

Provider documentation and authorization expectations

Document the neonate's present body weight in the operative report when billing modifier 63. Services billed with modifier 63 must meet prior authorization and medical necessity requirements appropriate to the procedure, diagnosis, and the member's state of residence. Use industry-standard codes (CPT, HCPCS, revenue codes) and ensure the medical record fully supports the billed services. Failure to follow coding/billing or policy requirements may result in claim denial, payment recovery, or reimbursement adjustment.

A neonate's present body weight must be recorded in the operative report when modifier 63 is used.
Verify prior authorization and medical necessity requirements before performing/billing the service.
Use compliant CPT/HCPCS/revenue codes supported by the medical record.
Anthem may reject/deny claims or recover payments if documentation or coding requirements are not met.

Billing Rule

Billing rule for assistants/multiple procedures

When an assistant surgeon is used and/or multiple procedures are performed on neonates or infants less than 4 kg in the same operative session, applicable assistant surgeon and multiple-procedure billing rules and fee reductions apply. Reimbursement for a procedure billed with modifier 63 is based on 100% of the applicable fee schedule or contracted rate when the modifier is valid; reductions for assistant services or multiple procedures are handled per standard billing rules.

Apply assistant surgeon billing rules and any associated fee reductions when an assistant is present.
Apply multiple-procedure rules and reductions when more than one procedure is performed in the same operative session.
Ensure modifier 63 is appropriate for the neonate/infant weight and supported in the operative report.

Key Definitions

inv-06: Modifier 63

Definition of Modifier 63Report modifier added to the procedure number for procedures performed on neonates and infants up to a present body weight of 4 kg

RationaleThese procedures may involve significantly increased complexity and additional physician or qualified healthcare professional work

Billing implicationWhen valid, modifier 63 may result in reimbursement at 100% of the applicable fee schedule or contracted/negotiated rate

Documentation expectationThe neonate's present body weight should be documented clearly in the report for the service