CurrentAnthemPolicy G-06015

Modifier 63, Reimbursement Policy

Defines Anthem Medicare Advantage reimbursement rules for use of CPT modifier 63 for surgery on neonates and infants up to a present body weight of 4 kg, and lists circumstances where modifier 63 is not reimbursable; applies to Anthem Medicare Advantage across listed states.

Policy Summary

PayerAnthem

PolicyModifier 63, Reimbursement Policy

Policy CodePolicy G-06015

Change TypeReview approved: no changes (09/06/2024)

Effective Date08/28/2020

Next Review Date

Key ActionDocument neonate weight in the operative report and follow authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

POLICY UPDATE CHANGES

Review approved: no changes.

11/04/2022 review updated minor language; updated title to only include modifier 63; updated definition for modifier 63.

08/28/2020 review updated policy language, Background, References and Research Materials, and Definitions sections.

4 kgmaximum present body weight for modifier 63 reimbursement

100%reimbursement percentage when modifier valid

Multiplenonreimbursable code categories

G-06015document identifier

Modifier 63 Coverage Criteria

Modifier 63 coverage criteria

Covered when ALL of the following are met:

ALL of the following

Procedure performed on neonate/infant with present body weight <= 4 kg
Neonate weight must be documented clearly in the operative report
Modifier 63 is valid for the billed procedure and documented
Reimbursement basis when modifier valid
Payment is 100% of the applicable fee schedule or contracted/negotiated rate for the procedure code

ALL of the following

Policy Summary

PayerAnthem

PolicyModifier 63, Reimbursement Policy

Policy CodePolicy G-06015

Change TypeReview approved: no changes (09/06/2024)

Effective Date08/28/2020

Next Review Date

Key ActionDocument neonate weight in the operative report and follow authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

On This Page

Modifier 63 is NOT reimbursable in any of the following circumstances

Modifier 63 billed for facility billing
Modifier 63 billed with Evaluation and Management (E/M) codes
Modifier 63 billed with anesthesia codes
Modifier 63 billed with radiology codes
Modifier 63 billed with pathology/laboratory codes
Modifier 63 billed with medicine codes (except where the medicine code is appropriate for the modifier)
Modifier 63 billed with modifier 63-exempt codes
Modifier 63 billed in addition to modifier 22 (unusual services) for the same procedure code(s)
Modifier 63 billed with codes that denote invasive procedures already including neonate/infant in the description (since those codes’ rates already reflect additional work)

Coding and Weight Threshold

Covered ModifiersModifierCovered

modifier 63

Use for procedures on neonates/infants up to present body weight of 4 kg to indicate increased complexity and work.

Nonreimbursable UsesModifierNot Covered

facility billing	Modifier 63 billed for facility billing is not reimbursable.
E/M codes	Modifier 63 billed with Evaluation and Management (E/M) codes is not reimbursable.
anesthesia codes	Modifier 63 billed with anesthesia codes is not reimbursable.
radiology codes	Modifier 63 billed with radiology codes is not reimbursable.
pathology/laboratory codes	Modifier 63 billed with pathology/laboratory codes is not reimbursable.
medicine codes	Modifier 63 billed with medicine codes (other than those appropriate for the modifier) is not reimbursable.
modifier 63-exempt codes	Modifier 63 billed with codes that are exempt from modifier 63 is not reimbursable.
modifier 22 combination	Modifier 63 billed in addition to modifier 22 for the same procedure code(s) is not reimbursable.
codes already denoting neonate/infant	Modifier 63 billed with codes that denote invasive procedures including neonate or infant in the description is not reimbursable because the code rate already reflects the additional work.

Weight threshold

Maximum present body weight for modifier 63 reimbursement4 kg

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

Documentation requirementNeonate weight must be documented clearly in the operative report

Provider Documentation and Authorization

Documentation Required

Provider Documentation and Authorization

Anthem Medicare Advantage requires clear provider documentation and, where applicable, prior authorization in accordance with the member's benefit plan and any applicable state, federal, or CMS requirements. For surgery on neonates and infants billed with modifier 63, the operative report must include the neonates present body weight. Services must meet authorization and medical necessity guidelines and be supported in the medical record. Failure to document the neonate weight or to obtain any required prior authorization may result in claim denial, payment recovery, or adjustment.

Document neonate/infant present body weight in the operative report (required).
Use modifier 63 when billing for surgery on neonates/infants up to 4 kg (when applicable).
Obtain prior authorization when required by the member's benefit plan, state, federal, or CMS rules.
Ensure medical necessity criteria are met and fully supported in the medical record.
When an assistant surgeon is used or multiple procedures are performed on neonates/infants <4 kg, apply assistant surgeon and multiple procedure rules and fee reductions.

OpenPayer

Modifier 63, Reimbursement Policy

Modifier 63 Coverage Criteria

Coding and Weight Threshold

Provider Documentation and Authorization

Definitions

Policy Revision History