CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO23

Modifier Reference Policy

Governs use and billing of CPT/HCPCS modifiers for Blue Cross Blue Shield of New Mexico claims processing and provider submissions; affects providers submitting claims to BCBSNM.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyModifier Reference Policy

Policy CodePolicy CPCPO23

Change TypeCoding and recommendation updates

Effective DateMar 22, 2023

Next Review Date

Key ActionSubmit claims with correct modifier-to-procedure code combinations and provide supporting documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Coding and recommendation updates were made on 03/17/2023.

Additional revisions were made on 05/13/2022.

Version 2.0policy version

Mar 22, 2023plan effective

Extensivemodifiers listed

6+update entries

Coverage Criteria

Modifier reimbursement criteria

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Append modifier only when the service or procedure is clinically supported for use of modifiers and documentation supports additional work or distinctness.

Do not append modifiers to circumvent National Correct Coding Initiative (NCCI) Procedure-to-Procedure edits when the service is not clinically supported for use of a modifier.

Claims may be denied for inappropriate modifier-to-procedure code combinations; a corrected claim submission with the correct modifier-to-procedure combination will be necessary for reimbursement.

Medical records or other documentation should accompany the claim to ensure appropriateness of claim reimbursement and may be requested by the plan.

If billing with more than one modifier, list the modifier that will impact reimbursement first.

Inclusion of a modifier in the policy does not guarantee reimbursement; some modifiers are informational only and reimbursement depends on claims logic and supporting documentation.

Modifier reimbursement and denial criteria

Modifiers that affect reimbursement or denial:

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

If a procedure requires an anatomical modifier and it is not appended, the claim will deny.

For DME rentals append RR; one unit of service is billed per monthly period unless classified as a daily rental.

Anesthesia-related modifiers (e.g., Qy, Qz, QK, QS, QX) must be appended in the circumstances described (medical direction, CRNA services with or without direction) and billed by the appropriate provider type.

HCPCS modifiers should not be submitted on claims with PQRI CPT Category II codes; ensure appropriate Category II modifier billing.

Coding and Modifiers

Representative modifiers describedCPT | HCPCS

22	Increased Procedural Services
25	Significant, separately identifiable E/M service
26	Professional component
50	Bilateral procedure
51	Multiple procedures
59	Distinct procedural service
76	Repeat procedure by same physician
77	Repeat procedure by another physician
95	Synchronous telemedicine service
GT	Via interactive audio and video telecommunications system

1–10 of 16

1/2

Anatomical modifiersModifierCovered

LT	Left (anatomical modifier)
RT	Right (anatomical modifier)
50	Bilateral procedure

Anesthesia modifiersModifierCovered

QK	Medical direction of three or four concurrent anesthesia procedures
QS	Monitored anesthesiology care service (MAC)
QX	CRNA service with medical direction by a physician
Qy	Medical direction of one CRNA by an Anesthesiologist
Qz	CRNA service without medical direction by a physician

Other common modifiersModifierCovered

RR	Rental (DME rentals billed one unit per monthly period unless daily rental)
SH	Second concurrently administered infusion therapy
SJ	Third or more concurrently administered infusion therapy (services with SJ will not be reimbursed)
UE	Used durable medical equipment
XE	Separate encounter (distinct because it occurred during a separate encounter)
XP	Separate practitioner (distinct because performed by different practitioner)
XS	Separate structure (distinct because performed on separate organ/structure)
XU	Unusual non-overlapping service (distinct because it does not overlap usual components)

inv-07: Modifier-to-procedure appropriateness

Policy requirementModifiers may be appended to CPT/HCPCS codes only when the service or procedure is clinically supported for use of modifiers; claims with inappropriate modifier-to-procedure combinations may be denied.

Avoid circumventing editsDo not append modifiers to circumvent NCCI Procedure-to-Procedure (PTP) edits when the service is not clinically supported for modifier use.

DocumentationMedical records or other documentation should accompany claims to ensure appropriateness of modifier use and reimbursement.

Ordering multiple modifiersIf billing with more than one modifier, list the modifier that will impact reimbursement first.

inv-08: DME rental billing frequency

DME rental billing frequencyAppend RR for DME rentals; one unit of service is billed per monthly period unless classified as a daily rental.

Used DMEAppend UE when billing used durable medical equipment.

Claim supportsDocumentation must support rental classification (monthly vs daily) to ensure correct unit billing.

Provider Actions and Billing Guidance

Documentation Required

Submit accurate documentation and respond to requests

Providers must submit accurate documentation of services performed and are expected to submit claims using valid HIPAA-approved code sets. Claims are subject to claim review against benefit terms, provider contracts, medical policies, CPCPs and coding software logic; upon request providers should submit additional supporting documentation.

Denial Risk

Risk of denial for inappropriate modifier-to-procedure combinations

Claims containing inappropriate modifier-to-procedure code combinations may be denied; a corrected claim submission with the correct modifier combination will be necessary to be considered for reimbursement.

Denial Risk

Append required anatomical modifiers or risk claim denial

If a procedure requires an anatomical modifier and it is not appended the claim will deny; append anatomical modifiers in box 24D of the CMS-1500 or report the first modifier in SV101-3 and use SV101-4/5/6 for additional modifiers.

Claims edit software validates procedure and modifier; missing or mismatched anatomical modifiers will cause denial.
Use CMS 1500 box 24D or SV101 fields for electronic submission as specified.

Billing Rule

Append anesthesia modifiers correctly and bill by appropriate provider

Append anesthesia-related modifiers (QK, QS, QX, Qy, Qz) per the described conditions (medical direction, monitored anesthesia care, CRNA direction/without direction) and bill the modifier information under the appropriate provider type (Anesthesiologist MD or CRNA).

QK — append when service was supervised by an Anesthesiologist; billed by an Anesthesiologist MD.
QS — append in second modifier position when accompanied by a pricing anesthesia modifier in the first position for monitored anesthesia care (MAC).
QX/Qy/Qz — append per CRNA medical direction/without direction rules and bill under the appropriate provider.

Definitions

inv-13: Modifier

FormatModifiers consist of two numeric or alphanumeric characters.

PurposeModifiers provide additional information about the services rendered and are appended to CPT/HCPCS procedure codes.

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

inv-14: Hierarchy of governing documents

Governing priorityIf a conflict arises between this CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contractsIf a conflict arises between this CPCP and any provider contract, the provider contract will govern where applicable.

Examples of plan documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

inv-15: Anatomical modifiers

PurposeAnatomical modifiers are appended to procedure codes to differentiate site (e.g., left vs right) and facilitate correct coding for claims processing.

Required useIf a procedure requires an anatomical modifier and it is not appended, the claim will deny.

Reporting locationAppend anatomical modifiers in box 24D of the CMS 1500 or electronically report the first modifier in SV101-3 and use SV101-4/5/6 for additional modifiers as needed.

inv-16: Anesthesia modifiers

Modifier definitionsQK, QS, QX, Qy, Qz denote anesthesia supervision/direction and CRNA relationships and indicate which provider bills the modifier information.

QK and QS usageQK = medical direction of three or four concurrent anesthesia procedures (billed by Anesthesiologist); QS = monitored anesthesiology care (append in second position when a pricing anesthesia modifier is first).

QX and Qy usageQX = CRNA service with medical direction by a physician (billed by CRNA/AA); Qy = medical direction of one CRNA by an Anesthesiologist (billed by Anesthesiologist).

Qz usageQz = CRNA service without medical direction by a physician (billed by CRNA).

Revision History

2023-03-17updateLatest

Coding and recommendation updates were made to the policy.

2022-05-13revision

Additional revisions were made to the policy.

2022-04-08annual_review

Annual review of the policy.

2021-03-31annual_review

Annual review of the policy.

2020-02-28annual_review

Annual review and disclaimer update.

2018-11-27new_policy

Policy established as a new policy.