ModifiedBlue Cross Blue Shield - IllinoisPolicy CPCP023

Modifier Reference Policy

Governs when and how CPT/HCPCS modifiers should be appended to procedure codes for claims submitted to Blue Cross Blue Shield of Illinois; affects providers billing BCBSIL for covered services.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeModifiers added and one removededitorial clarifications

Effective DateOct 31, 2025

Next Review DateJul 25, 2025

Key ActionSubmit claims with accurate documentation and valid modifier-to-procedure code combinations; provide supporting records upon request.

SourceLink

POLICY UPDATE CHANGES

Additional modifiers added: 63, 96, 97, GA, KD, KH, KI, KJ, KL, KM, KN, KR, LL, Q6, RA, RB.

Modifier JG was removed.

Grammatical updates to policy language and specific modifier sections (22, 23, 26, 33, 50, 51, 52, 57, 93, 95, LU, TB, XE, XP, XS, XU).

two-charactermodifier format

all validaccepted modifiers

multiplemultiple modifiers

may denymay deny

~70+

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documented modifiers

10CAR-T fraction units

Modifier Coverage Criteria & Claim Handling

Modifier application and claim handling

Covered when ALL of the following are met:

Modifiers may be appended to CPT/HCPCS codes only when the service or procedure is clinically supported for use of the modifier.

A claim must be submitted with the correct modifier-to-procedure code combination; modifiers should not be appended if the service does not support the modifier.

Claims containing inappropriate modifier-to-procedure code combinations may be denied; if denied, providers must submit a corrected claim with the correct modifier-to-procedure code combination to be considered for reimbursement.

The plan may request supporting medical records or other documentation to determine appropriate claim reimbursement; providers must supply documentation upon request.

When billing with more than one modifier, list the modifier that impacts reimbursement first on the claim line.

Modifier coverage and billing rules

Billing and reimbursement rules for modifiers that affect coverage or adjudication:

Procedure codes and modifier combinations are validated against a set of required modifiers by procedure; if a procedure with a required modifier does not have the modifier appended, the claim line(s) will deny.

If an anatomical modifier is necessary to differentiate laterality (e.g., right vs left) and it is not appended, the claim line(s) will be denied. If a modifier is appended that does not match the appropriate anatomical site, the claim line(s) will be denied.

Modifier SJ (third or more concurrently administered infusion therapy) denotes services that will not be reimbursed when submitted with SJ appended.

CAR-T HCPCS codes billed with modifier LU must be fractionated by dividing the allowed total payment by 10 and billing in 0.1-unit fractions; providers should bill a total of 10 fractional units to reach the total allowed payment amount. REMS‑approved facilities must append LU, 76, and KX.

When billing multiple modifiers, list the modifier impacting reimbursement first on the claim line.

Modifier Coding, Lists, and Format

General modifier format and acceptanceModifier

modifier (2 characters)

Modifiers consist of two numeric or alphanumeric characters and provide additional information about services rendered.

Listed modifiers and descriptions (not exhaustive)Modifier

22	Increased Procedural Services — append when service is significantly greater than usual; documentation must support substantial additional work.
23	Unusual anesthesia — append when a procedure that typically requires no anesthesia was performed under general anesthesia due to unusual circumstances.
24	Unrelated E/M during postoperative period by same physician.
25	Significant, separately identifiable E/M on same day as procedure.
26	Professional component — append when physician interprets results and provides written report.
TC	Technical component — used when only the technical component is billed.
33	Preventive services — append for evidence-based preventive services as specified.
47	Surgeon-performed anesthesia (by surgeon) — used in specific circumstances for MAC pricing.
50	Bilateral procedure.
51	Multiple procedures.

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ModifiersModifier

G9	Monitored anesthesia care (MAC) for severe cardiopulmonary condition.
GA	Waiver of liability statement issued as required by payer policy.
GC	Service performed in part by a resident under teaching physician direction.
GE	Service performed by resident without physician present under primary care exception.
GF	Nonphysician services in a critical access hospital.
GP	Outpatient physical therapy plan of care.
GT	Interactive audio and video telecommunications system (telehealth).
HM	Less than bachelor's degree level (ABA services for CPT 97153).
HN	Bachelor's degree level (ABA services for CPT 97153).
HO	Master's degree level or higher (ABA services for CPT 97153); reimbursement defaults to HM if HO not appended.

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1/5

Anatomical modifiersModifier

E1-E4	Eyelids anatomical modifiers.
F1-F9	Fingers anatomical modifiers.
T1-T9	Toes anatomical modifiers.
LC	Left circumflex coronary artery.
LD	Left anterior descending coronary artery.
LM	Left main coronary artery.
LT	Left side.
RI	Ramus intermedius coronary artery.
RC	Right coronary artery.
RT	Right side.

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1/2

Modifier placement

RuleWhen billing with more than one modifier, list the modifier that impacts reimbursement first on the claim line.

RationaleSome modifiers carry claims logic that affects reimbursement or adjudication; listing the reimbursement-impacting modifier first ensures correct pricing and adjudication.

Claim field guidanceFor paper claims, place modifiers in CMS-1500 box 24D; for electronic claims, populate SV101-3 (first modifier) with the reimbursement-impacting modifier.

ScopeApplies to all CPT and HCPCS claims submitted to BCBSIL where multiple modifiers are reported.

CAR-T fractional billing units

Billing Requirements, Documentation, and Reimbursement Actions

Documentation Required

Claims submission and documentation

Submit claims with accurate documentation and use valid modifier-to-procedure code combinations. Upon request, provide supporting medical records or other documentation to help determine appropriate claim reimbursement; incorrect modifier use may result in claim denial and require submission of a corrected claim.

Use HIPAA-approved code sets and industry-standard coding guidelines when coding claims.
Be prepared to submit additional documentation when the plan requests supporting records.

Billing Rule

Anatomical modifier billing and validation

Ensure required anatomical modifiers are appended and accurately reflect the anatomical site; missing or mismatched anatomical modifiers will cause the claim line(s) to deny. Report anatomical modifiers in CMS 1500 box 24D or electronically as the first modifier in SV101-3 (use SV101-4–6 for additional modifiers).

Key Terms and Definitions

Modifier — definition

DefinitionModifier — a two-character numeric or alphanumeric code appended to CPT/HCPCS procedure codes to provide additional information about the service rendered.

AcceptanceAll valid CPT and HCPCS modifiers are accepted into the claims processing system used to review claims submitted to BCBSIL.

ImpactSome modifiers have claims logic that may impact claim reimbursement while others are informational only; inappropriate modifier use may result in denial.

Modifier (format)

FormatModifiers consist of two numeric or alphanumeric characters (two-character format).

UsageModifiers are appended to CPT and HCPCS codes to convey additional information about the service rendered.

Policy Changes & Document History

2018-11-27policy_created

Policy created (new policy).

2020-02-28annual_review

Annual review and disclaimer update.

2021-03-31annual_review

Annual review.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeModifiers added and one removededitorial clarifications

Effective DateOct 31, 2025

Next Review DateJul 25, 2025

Key ActionSubmit claims with accurate documentation and valid modifier-to-procedure code combinations; provide supporting records upon request.

SourceLink

On This Page

Examples of modifier effects (select as applicable)

For ABA CPT 97153, append modifiers HM/HN/HO to indicate provider education/certification level; if HO is not appended, reimbursement defaults to HM.
Append JW to report discarded drug amounts and JZ when zero amount discarded; append KD for drugs or biologicals infused through DME.
Append PD for physician preadmission diagnostic or related nondiagnostic services provided within three days of inpatient admission to indicate three-day window payment rules; reimbursement differs by PC/TC split or facility rate as applicable.
Modifiers XE/XP/XS/XU require supporting documentation to justify separate encounter, separate practitioner, separate structure, or unusual non‑overlapping service respectively in order to be billed appropriately.

Providers should append anatomical modifiers in box 24D of the CMS‑1500 claim form or electronically report the first modifier in SV101‑3 and additional modifiers in SV101‑4/5/6 as needed.

When billing CAR-T HCPCS codes with modifier LU, divide the allowed total payment by 10 and bill in 0.1-unit fractions (bill a total of 10 fractional units to reach the allowed payment).

Modifiers required for REMS facilitiesREMS‑approved facilities must append LU plus modifiers 76 and KX when fractionating CAR‑T payments.

Unit sizeEach fractional unit billed should be 0.1 to accumulate to the full allowed payment when 10 units are submitted.

PurposeFractional billing with LU enables distribution of the total allowed payment across multiple claim lines as required for CAR‑T codes.

If a procedure requires a specific anatomical modifier and it is not appended, the claim line(s) will deny.
If an anatomical modifier appended does not match the appropriate anatomical site, the claim line(s) will deny.

Billing Rule

CAR-T fractional billing

When billing CAR‑T HCPCS codes with modifier LU, divide the allowed total payment by 10 and bill in 0.1‑unit fractions; providers should bill a total of 10 fractional units to reach the total allowed payment amount. REMS‑approved facilities must append LU plus modifiers 76 and KX.

Divide allowed total payment by 10 and bill in 0.1-unit increments.
Submit a total of 10 fractional units to equal the allowed payment.
REMS‑approved facilities must use LU, 76, and KX.

Denial Risk

Concurrent infusion reimbursement restriction (SJ)

Services submitted with modifier SJ (third or more concurrently administered infusion therapy) will not be reimbursed.

Do not expect payment for services reported with modifier SJ; adjust billing and clinical workflow to avoid third-or-more concurrent infusion reporting when reimbursement is required.

System acceptanceBCBSIL accepts all valid CPT and HCPCS modifiers into its claims processing system.

Anatomical modifier

DefinitionAnatomical modifier — a code appended to a procedure to indicate the specific body part or site (e.g., left vs right) for correct claim processing.

Denial riskIf a procedure requires a specific anatomical modifier and it is not appended, the claim line(s) will deny; mismatched anatomical modifiers also cause denials.

Claim form guidanceProviders should append anatomical modifiers in CMS 1500 box 24D or electronically report the first modifier in SV101-3 and additional modifiers in SV101-4/5/6 if needed.

ExamplesListed anatomical modifiers include E1–E4 (eyelids), F1–F9 (fingers), T1–T9 (toes), LC/LD/LM (coronary arteries), LT/RT (left/right), RI/RC (coronary branches), and 50 (bilateral).

Concurrent infusion modifiers (SH, SJ)

SH — Second concurrent infusionModifier SH indicates a second concurrently administered infusion therapy (used to identify the second concurrent infusion).

SJ — Third or greater concurrent infusionModifier SJ denotes a third or more concurrently administered infusion therapy and services submitted with SJ will not be reimbursed.

Billing consequenceServices submitted with modifier SJ appended will not be reimbursed; ensure correct modifier sequencing to avoid improper denials or nonpayment.

Placement noteWhen multiple infusion modifiers apply, follow modifier placement guidance and list reimbursement‑impacting modifiers first on the claim line.

2022-04-08annual_review

Annual review.

2022-05-13update

Additional revisions to policy content.

2023-03-17coding_update

Coding and recommendation updates.

2023-10-30update

Additional revisions.

2024-01-12annual_review_and_coding_updates

Annual review with coding and recommendation updates.

2025-07-25annual_review_material_changesLatest

Annual review with grammatical updates to multiple modifier sections and material changes: added modifiers 63, 96, 97, GA, KD, KH, KI, KJ, KL, KM, KN, KR, LL, Q6, RA, RB and removed modifier JG; resources and references updated.