CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP023

Modifier Reference Policy

Defines accepted CPT/HCPCS modifiers, guidance for when to append modifiers, and reimbursement/billing implications for providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeNo material changes

Effective DateOct 31, 2025

Next Review DateJul 25, 2025

Key ActionSubmit corrected claims when an inappropriate modifier-to-procedure code combination results in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All valid modifiersaccepted into claims processing system

40+modifiers listed

Order mattersmodifier order rule

Claims may be denieddenial risk

2018-2025revision history

Modifier Submission and Reimbursement Rules

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Modifier submission and reimbursement rules

Modifier use and reimbursement stance

Modifiers may be appended to CPT/HCPCS code(s) if the service or procedure is clinically supported for use of the modifiers.

Submit claims with the correct modifier-to-procedure code combination; inappropriate modifier-to-procedure combinations may be denied and require submission of a corrected claim to be considered for reimbursement.

All valid CPT and HCPCS modifiers are accepted into the claims processing system used to review claims submitted; inclusion in the system does not guarantee reimbursement as some modifiers affect claim logic and reimbursement while others are informational only.

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

The plan may request medical records or other documentation to determine appropriate claim reimbursement; the plan reserves the right to request supporting documentation.

Modifier billing and reimbursement rules

Modifier-related billing rules and reimbursement stance in this fragment:

Procedure codes and modifier combinations are validated against a set of required modifiers by procedure; if a required modifier is missing or incorrect the claim line(s) will deny.

If an anatomical modifier is necessary to differentiate right/left (or other specified anatomical site) and is not appended, the claim line(s) will be denied.

If a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim line(s) will be denied.

SJ (third or more concurrently administered infusion therapy) denotes third or more concurrent infusions and services submitted with SJ will not be reimbursed.

When billing with multiple modifiers, list the modifier impacting reimbursement first (apply modifier order rule consistently).

Examples / operational notes

Accepted Modifiers and Individual Modifier Guidance

Accepted modifiersModifier

all CPT/HCPCS modifiers

All valid CPT and HCPCS modifiers are accepted into the claims processing system; modifiers consist of two numeric or alphanumeric characters.

Individual modifier guidanceModifier

22	Increased Procedural Services; append when service is significantly greater than usual; documentation should support substantial additional work (time, severity, intensity).
23	Unusual anesthesia; append when procedure typically not requiring anesthesia performed under general anesthesia due to unusual circumstances.
24	Unrelated E/M during postoperative period; append for unrelated E/M by same physician during postoperative period.
25	Significant, separately identifiable E/M on same day as procedure; documentation must satisfy relevant criteria.
26	Professional component; append when physician interprets test results and provides written report.
TC	Technical component; use when only technical component is billed.
33	Preventive services; append for services represented for evidence-based preventive services per USPSTF A/B and mandates.
47	Surgeon-performed anesthesia; append when surgeon provides regional/general anesthesia (limited use).
50	Bilateral procedure; append for procedures on identical anatomic sites.
51	Multiple procedures; append to additional procedures in same session.

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Not exhaustive modifier list from this fragmentModifier

FQ	Service furnished using audio-only communication technology
FR	Supervising practitioner present via two-way audio/video
G0	Telehealth for acute stroke
G8	MAC for deep/complex surgical procedure (second modifier position)
G9	MAC for patient with severe cardiopulmonary condition (second modifier position)
GA	Waiver of liability (Advance Member Notice)
GC	Service performed in part by resident under direction of teaching physician
GT	Interactive audio and video telecommunication system
HM	ABA provider less than bachelor's degree
HN	ABA provider bachelor's degree level (affects CPT 97153 reimbursement default)

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inv-06: Documentation required for atypical modifier use — plan may request supporting documentation

Plan rightsMedical records or other documentation may be requested to determine appropriate claim reimbursement; the plan reserves the right to request supporting documentation.

When documentation requestedDocumentation may be requested when modifier use is atypical or when claim reimbursement requires validation of modifier-to-procedure code combinations.

Provider responsibilityProviders are urged to submit any additional documentation upon request to support the modifier and service billed.

Corrected claimsIf claim contains an inappropriate modifier-to-procedure code combination and is denied, providers must submit a corrected claim with appropriate documentation.

inv-07: ABA CPT 97153 reimbursement default — If HN or HO not appended, reimbursement defaults to HM

ABA CPT 97153 modifiersModifiers HM, HN, HO indicate ABA provider education/certification level for CPT 97153 and affect reimbursement.

Reimbursement default ruleIf modifier HN or HO is not appended when billing CPT 97153, reimbursement will default to modifier HM.

When to append HN/HOAppend HN when rendering provider has a bachelor’s degree level or is an RBT/BCaBA; append HO when provider has a master’s degree or higher (BCBA/BCBA-D).

Billing, Documentation, and Claim Correction Responsibilities

Documentation Required

Documentation upon request

Providers are responsible for submission of accurate documentation of services performed. Upon request, the provider must submit any additional documentation to support modifier use and claim reimbursement. The plan reserves the right to request supporting documentation to determine appropriate claim reimbursement.

Billing Rule

Corrected claims requirement

If a claim contains an inappropriate modifier-to-procedure code combination that results in a denial, providers are required to submit a corrected claim with the correct modifier-to-procedure code combination to be considered for reimbursement. Medical records or other documentation may be requested to support the corrected claim.

Denial Risk

Modifier validation and denials

Procedure codes and modifier combinations are validated against required modifiers by procedure. Missing required modifiers, incorrect anatomical modifiers (including omitted right/left modifiers), or modifiers that do not match the appropriate anatomical site may result in denial of the claim line(s). Append anatomical modifiers in box 24D of the CMS-1500 or electronically report as SV101-3 (first modifier) and SV101-4/5/6 for additional modifiers as needed.

Key Terms and Definitions

inv-11: Modifier — definition and effect on claims

DefinitionTwo numeric or alphanumeric characters appended to CPT/HCPCS codes to provide additional information about the services rendered.

FunctionModifiers can provide clinical or billing information; some affect reimbursement while others are informational only.

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

inv-12: Plan documents governing conflicts — Certificates, benefit booklets, and other coverage documents govern over this policy

Governing documentsIf a conflict arises between this policy and a plan document, the plan document (e.g., Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions) will govern.

Provider contractsIf a conflict arises between this policy and a provider contract, the provider contract will govern.

BCBSNM discretionBlue Cross and Blue Shield of New Mexico may use reasonable discretion in interpreting and applying this policy to services being delivered in a particular case.

inv-13: Anatomical modifier — identifies anatomical site; required for correct coding

PurposeAnatomical modifiers identify the anatomical site (e.g., left/right, specific coronary arteries, eyelids, fingers, toes) and facilitate correct coding for claims processing.

Denial riskIf an anatomical modifier required to differentiate right/left is not appended, or if the appended modifier does not match the appropriate anatomical site, the claim line(s) will be denied.

Submission locationProviders should append the anatomical modifier in box 24D of the CMS 1500 form or report it electronically as the first modifier in SV101-3; additional SV101 fields may be used as needed.

inv-14: FQ modifier — indicates audio-only telecommunication when video not available

DefinitionModifier FQ indicates the service was furnished using audio-only communication technology when the patient is unable to use audio and video communications.

When to appendAppend FQ when a service is rendered using audio-only technology that allows two-way, real-time communication.

Related telehealth modifiersOther telehealth modifiers include FR (supervising practitioner present via audio/video), GT (interactive audio and video), and G0 (telehealth for acute stroke).

inv-15: XE/XP/XS/XU modifiers — distinct service modifiers (separate encounter/practitioner/structure/non-overlap) and documentation expectations

PurposeXE/XP/XS/XU modifiers denote distinct service based on separate encounter (XE), separate practitioner (XP), separate structure (XS), or unusual non-overlapping service (XU).

Documentation requirementTo bill XE/XP/XS/XU, documentation must support that the service is distinct for the stated reason (separate encounter/practitioner/structure/non-overlap).

Billing noteThese modifiers are used to indicate distinctness of a service and require supporting documentation to validate reimbursement and claims processing.