CurrentBlue Cross Blue Shield - MainePolicy C-23005

Modifier Usage - Facility

This policy governs how facility providers should bill and use CPT/HCPCS modifiers for reimbursement by Anthem Blue Cross and Blue Shield (Blue Cross Blue Shield - Maine) and describes documentation and billing expectations that affect payment. It applies to facility claims for covered services for eligible members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier Usage - Facility

Policy CodePolicy C-23005

Change TypeNo material changes

Effective DateMay 1, 2024

Next Review Date

Key ActionSubmit supporting documentation with claims when required modifiers are used; claims missing correct modifiers may be rejected or denied and must be resubmitted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

05/01/2024effective date

11/08/2023last approval

Facilityprovider scope

3pages

Modifier Billing and Reimbursement Criteria

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Claims must be billed with appropriate procedure codes and appropriate modifiers when applicable; modifier format must use capital letters for alpha or alphanumeric modifiers.

From policy: The Health Plan allows reimbursement...when billed with appropriate procedure codes and appropriate modifiers... The modifier must be in capital letters, if alpha or alphanumeric.

Reimbursement modifiers (those that affect payment) must be billed in the primary or first modifier field locator.

Reimbursement modifiers affect payment and must be billed in the primary or first modifier field locator.

Informational modifiers that impact reimbursement should be billed after reimbursement modifiers in subsequent modifier fields; informational modifiers that do not impact reimbursement are for documentation and billed in later modifier fields.

Informational Modifiers Impacting Reimbursement: Informational modifiers determine if the service provided will be reimbursed or denied... billed in modifier locator fields after reimbursement modifiers.

Use of certain modifiers requires the provider to submit supporting documentation with the claim; claims billed without the correct modifier in the correct format may be rejected or denied and must be resubmitted subject to timely filing. Use of correct modifiers does not guarantee reimbursement.

Provider documentation requirement and claim resubmission rules.

Anthem reserves the right to review adherence to correct coding for high-volume modifiers; providers should follow specific modifier policies for documentation guidance.

Coding review right and reference to specific modifier policies.

Documentation, Claim Resubmission, and Coding Review

Documentation Required

Provide required supporting documentation and resubmit corrected claims

The policy requires providers to submit supporting documentation when certain modifiers are used and to resubmit rejected/denied claims with the correct modifier and associated code‑set. Claims billed without the correct modifier (in the correct format) may be rejected or denied; corrected and resubmitted claims are subject to timely filing guidelines.

Submit supporting documentation with the claim when required by the specific modifier policy.
If a claim is rejected or denied for an incorrect or missing modifier, resubmit with the correct modifier (must be in capital letters for alpha/alphanumeric modifiers) and the related code‑set.
Resubmitted claims remain subject to timely filing rules; use of correct modifiers does not guarantee payment.

Denial Risk

Anthem may review high‑volume modifier coding

Anthem reserves the right to review coding for high‑volume modifiers and to take action if coding does not adhere to policy.

Anthem may review adherence to correct coding for high‑volume modifiers.
Claims lacking correct modifier format or coding may be rejected or denied, which could trigger further review or audit.
Ensure modifier use follows the policy (modifier in capital letters if alpha/alphanumeric) to reduce risk of adjustment or denial.

Definitions

Definitions — general reimbursement policy definitions referenced in the document

DefinitionsGeneral Reimbursement Policy Definitions as listed in the policy document.

ScopeDefinitions apply to facility billing and modifier usage under this reimbursement policy for eligible members.

ModifierA code appended to a procedure code to indicate that a service or procedure has been altered by some specific circumstance, per the policy definitions.

Reimbursement modifiersModifiers that affect payment and must be billed in the primary or first modifier field locator.

Informational modifiersModifiers used for documentation; may or may not impact reimbursement and should be billed after reimbursement modifiers.