CurrentBlue Cross Blue Shield - MainePolicy G-06015

Modifier 63 (neonate/infant surgery reimbursement)

Defines Anthem Medicare Advantage reimbursement rules for using CPT modifier 63 when billing surgical procedures performed on neonates and infants up to a present body weight of 4 kg; applies to professional and facility claim submission practices unless superseded by provider, state, federal, or CMS contracts.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 63 (neonate/infant surgery reimbursement)

Policy CodePolicy G-06015

Change TypeReview approved (no material changes in 09/06/2024)

Effective DateAug 28, 2020

Next Review Date

Key ActionDocument neonate weight in the operative report when billing with 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: updated title to only include modifier 63 and updated definition for modifier 63.

4 kgmaximum present body weight

100%reimbursement when valid

multiplepolicy history entries

Anthem MApayer scope

Modifier 63 Reimbursement Criteria

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 63 (neonate/infant surgery reimbursement)

Policy CodePolicy G-06015

Change TypeReview approved (no material changes in 09/06/2024)

Effective DateAug 28, 2020

Next Review Date

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

SourceLink

On This Page

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Modifier 63 reimbursement criteria and exclusions

Anthem Medicare Advantage reimbursement stance and exclusions for modifier 63:

ALL of the following

Patient present body weight must be <= 4 kg and documented in the service report
Neonate weight should be documented clearly in the report for the service.
Modifier 63 billed on professional claims for surgical procedures performed on neonates/infants up to 4 kg
Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate when the modifier is valid.
When an assistant surgeon is used and/or multiple procedures are performed in the same operative session on neonates/infants < 4 kg, assistant surgeon and multiple procedure rules and fee reductions apply.

Exclusions - modifier 63 is not reimbursable in any of the following situations:

Facility billing
With Evaluation and Management (E/M) codes
With anesthesia codes
With radiology codes
With pathology/laboratory codes
With medicine codes (other than those appropriate for the modifier)
With modifier 63-exempt codes
In addition to modifier 22 (unusual services) for the same procedure code(s)
With codes that denote invasive procedures that already include neonate or infant in the description (because such codes' reimbursement already reflects additional work)

ALL of the following

Policy applies to Anthem Medicare Advantage professional and facility claim submission practices unless superseded by provider, state, federal, or CMS contracts or requirements.

Documentation, Authorization, and Billing Requirements

Documentation Required

Documentation & Authorization — record neonate weight and meet authorization/medical necessity

Document the neonate's present body weight in the operative/service report and ensure all services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

The neonate weight should be documented clearly in the report for the service.
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member's state of residence.

Billing Rule

Billing Compliance — use compliant CPT/HCPCS/revenue codes supported by records

Follow proper billing and submission guidelines using industry-standard CPT, HCPCS, and/or revenue codes; all billed codes must be supported by the medical record or office notes.

You are required to use industry standard, compliant codes on all claim submissions.
Services should be billed with CPT codes, HCPCS codes, and/or revenue codes and must be fully supported in the medical record and/or office notes.
Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection/denial or recovery/recoupment of payment.

Modifier Definitions

Modifier 63 — definition and rationale

DefinitionModifier 63 indicates a procedure performed on a neonate or infant up to a present body weight of 4 kg due to significantly increased complexity and physician work

Reporting instructionReport by adding modifier 63 to the procedure number when applicable

RationaleUsed because procedures on these patients commonly involve increased complexity and additional physician effort

DocumentationNeonate weight should be documented clearly in the service/operative report when billing with modifier 63

OpenPayer

Modifier 63 (neonate/infant surgery reimbursement)

Modifier 63 Reimbursement Criteria

Relevant Codes and Weight Threshold

Documentation, Authorization, and Billing Requirements

Modifier Definitions