CurrentBlue Cross Blue Shield - MainePolicy C-08010

Modifier Rules - Professional

Defines Anthem Blue Cross Blue Shield - Maine's handling, validation, documentation, and adjudication impact of CPT/HCPCS modifiers for professional claims; applies to professional providers billing Anthem members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier Rules - Professional

Policy CodePolicy C-08010

Change TypeMaterial and minor code additions

Effective Date07/01/2024

Next Review Date

Key ActionSubmit supporting documentation with claims when using certain modifiers; resubmit denied lines corrected for invalid modifier–procedure combinations.

SourceLink

POLICY UPDATE CHANGES

Added modifier FT is required for unrelated evaluation and management (E/M) visits during a postoperative period for critical care codes 99291, 99292, 99468, 99469, 99471, 99472, 99475, and 99476.

Added modifiers 93 and FQ to the policy.

Added modifier FS to Informational Modifiers.

C-08010Policy identifier

07/01/2024Effective

04/01/2024Last approval

MultipleHistory

Modifier Adjudication and Documentation Criteria

Modifier adjudication and documentation criteria

Rules governing modifier use and adjudication:

Modifiers must be HIPAA‑compliant AMA CPT or HCPCS modifiers and reported following CPT and CMS coding guidelines.

The use of certain modifiers requires the provider to submit supporting documentation with the claim; refer to specific modifier policies for documentation guidance.

The Health Plan reserves the right to review adherence to correct coding for high‑volume modifiers.

If multiple procedures are performed on the same date and one line includes a site‑specific modifier, all subsequent procedure codes must also include a site‑specific modifier. If subsequent lines lack a site‑specific modifier, those procedures will be considered same site as the modified procedure and may be denied.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier Rules - Professional

Policy CodePolicy C-08010

Change TypeMaterial and minor code additions

Effective Date07/01/2024

Next Review Date

Key ActionSubmit supporting documentation with claims when using certain modifiers; resubmit denied lines corrected for invalid modifier–procedure combinations.

SourceLink

On This Page

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Modifier Coding and Percentage Rules

Recently added/updated modifiersmixed

FT	Required for unrelated E/M visits during postoperative period for specified critical care codes (99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476)
93	Added to policy (no further detail in document)
FQ	Added to policy (no further detail in document)
FS	Added to Informational Modifiers (no further detail in document)

Modifier percentage multiplication rule

RuleWhen multiple percentage-based modifiers apply to a procedure, multiply the percentage amounts together to determine a new percentage amount.

RoundingIf the computed new percentage contains a decimal, round the new percentage up to the next whole percent.

ApplicationApply the resulting whole percentage amount to the allowance for the procedure the modifier was reported with.

Provider Documentation, Denials, and Site-Specific Rules

Documentation Required

Documentation Requirement for Certain Modifiers

The Health Plan accepts all HIPAA-compliant AMA CPT and HCPCS modifiers for claims processing. Providers must follow proper coding guidelines as set by CPT and CMS when reporting modifiers. Certain modifiers require supporting documentation to be submitted with the claim; refer to the specific modifier policies for documentation guidance. The Health Plan reserves the right to review adherence to correct coding for high-volume modifiers.

Providers should submit supporting documentation when required by the specific modifier policy.
The Health Plan may review coding adherence for high-volume modifiers.

Denial Risk

Invalid Modifier–Procedure Combinations

When an invalid modifier-to-procedure combination is detected, the line item will be denied and the provider will be asked to resubmit with the correct code and modifier combination. The Health Plan uses modifier-to-procedure validation to identify inappropriate modifier use. Providers should verify modifier applicability per CPT/CMS guidance before submission to avoid denials.

Invalid modifier-procedure combinations will result in denial of the affected line item.
Providers must resubmit corrected code/modifier combinations for denied lines.

Billing Rule

Site-Specific Modifier Requirement

When multiple procedures are performed on the same date of service and one line includes a site-specific modifier, all subsequent procedure lines must also include a site-specific modifier. If only one line is reported with a site-specific modifier and subsequent lines are reported without one, the Health Plan will consider the additional procedures to be performed at the same site as the modified procedure, which may result in denial of the subsequent procedure(s).

If one procedure line includes a site-specific modifier, include the site-specific modifier on all other procedure lines for that date of service.
Failure to append site-specific modifiers to subsequent lines may lead to denial of those procedures.

Definitions

Modifier

DefinitionA modifier is a two-character alpha/numeric indicator appended to a CPT or HCPCS code that further defines or alters the code without changing the procedure definition.

Adjudication impactSome modifiers are informational only; others affect claim adjudication or the percentage of the allowance and must be reported per CPT/CMS guidelines.

Documentation requirementUse of certain modifiers requires providers to submit supporting documentation with the claim; refer to specific modifier policies for guidance.

Validation and denialsThe Health Plan validates modifier-to-procedure code combinations; invalid combinations will be denied and must be resubmitted with the correct code/modifier.