CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP023

Modifier Reference Policy

Reference policy describing appropriate use and billing of CPT/HCPCS modifiers for Blue Cross Blue Shield - Oklahoma claims; governs providers submitting claims to BCBSOK and describes documentation, claim submission expectations, and modifier-specific guidance.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeNo material changes — informational/reference update

Effective DateJanuary 25, 2024

Next Review DateN/A

Key ActionSupport modifier use with documentation; maintain records and submit correct modifier-to-procedure code combinations to avoid denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Version 3.0policy version

2024-01-25plan effective date

2024-01-12committee approval date

100+modifiers described or referenced

Policy Snapshot

This Modifier Reference (CPT/HCPCS) for claims policy (CPCP023) is CURRENT and serves as a reference describing appropriate use and billing of CPT and HCPCS modifiers for providers submitting claims to Blue Cross Blue Shield - Oklahoma. It defines modifier types, documentation expectations, claim submission rules, modifier ordering and positioning (including anesthesia/MAC guidance), and highlights that some modifiers affect reimbursement while others are informational. The policy is effective January 25, 2024 and approved by the committee on January 12, 2024.

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Applicability and Clinical Criteria

This policy is a reference describing appropriate use and billing of CPT/HCPCS modifiers for Blue Cross Blue Shield - Oklahoma claims. It governs providers submitting claims to BCBSOK, requires submission of valid HIPAA-approved code combinations, and sets expectations for documentation to support modifier use, correct modifier-to-procedure pairings, anatomical modifier reporting (e.g., box 24D on the CMS 1500 or electronic SV101 fields), and that claims are subject to code edit protocols and case-by-case review.

Modifier Reference (CPT/HCPCS) — Groups and Guidance

Numeric and alpha modifiers with guidanceModifier

22	Increased Procedural Services — append when service is significantly greater than usual; not for E/M; documentation required.
23	Unusual anesthesia — append in second modifier position for MAC when pricing anesthesia modifier is first; may be reported when general anesthesia used unexpectedly.
24	Unrelated E/M during postoperative period — append for unrelated E/M by same physician during post-op.
25	Significant, separately identifiable E/M on same day as procedure — append when documentation supports separate E/M.
26	Professional component — use when physician interprets but does not perform test.
TC	Technical component — used when only technical component is billed; report in first modifier field.
33	Preventive services — append for USPSTF A/B and other mandated preventive services; not for codes inherently preventive.
47	Anesthesia by surgeon — used for surgeon-provided regional/general anesthesia (not anesthesiologist); guidance notes anesthesiologist not covered with this modifier.
50	Bilateral procedure — for identical anatomic sites; do not use if code descriptor already indicates bilateral; do not bill LT/RT with Modifier 50 on same line.
51	Multiple procedures — append to additional procedures; do not use on exempt codes or all codes.

1–10 of 75

1/8

All valid CPT and HCPCS modifiers are accepted into the BCBSOK claims processing system; however, claims remain subject to code edit protocols and review. Inclusion of a modifier in this document does not guarantee reimbursement.

What Providers Must Do

Documentation Required

Support modifier use with documentation

Providers must maintain documentation supporting modifier use (e.g., rationale for modifier 22, distinct service for modifier 59, separate encounter for XE). Documentation may be requested and is required to determine appropriate reimbursement.

Billing Rule

Submit correct modifier-to-procedure code combinations

Claims must be submitted with correct modifier-to-procedure code combinations. Inappropriate combinations may be denied; providers must submit corrected claims for reimbursement consideration.

Billing Rule

Order of multiple modifiers

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

Billing Rule

Anatomical modifier requirements

Append required anatomical modifiers (e.g., RT, LT or specific site modifiers) when necessary; claims will deny if required anatomical modifier is missing or not matching the procedure site.

Denial Risk

Denial risk for incorrect modifiers

Claim lines will deny if a required modifier is missing or if a modifier is appended that does not match the procedure/site or required modifier set. Some modifiers (e.g., SJ) will produce non-reimbursement.

Documentation Required

Anesthesia and MAC modifier positioning

When reporting monitored anesthesia care (MAC) or anesthesia modifiers that impact pricing, append the pricing anesthesia modifier in the first modifier position and related MAC/secondary anesthesia modifiers in the second modifier position.

Documentation Required

Anatomical modifier reporting fields

Providers should append anatomical modifiers in box 24D of the CMS 1500 form or electronically report first modifier in SV101-3 and additional modifiers in SV101-4 through SV101-6 as needed.

Key Terms

Key definitions

ModifierTwo numeric or alphanumeric characters appended to CPT/HCPCS codes to provide additional information about services rendered; may affect reimbursement or be informational.

Anatomical ModifiersModifiers used to indicate laterality or specific anatomical sites (examples: LT, RT, E1-E4, F1-F9, T1-T9, LC, LD, LM, RI, RC). Required by procedure when applicable.

MACMonitored Anesthesia Care — anesthesia service that may require specific modifier positioning relative to pricing anesthesia modifiers.

Policy Update Log

2018-11-27policy_created

New policy.

2020-02-28annual_review

Annual Review, Disclaimer Update.

2021-03-31annual_review

Annual Review.

2022-04-08annual_review

Annual Review.

2022-05-13revision

Additional revisions.

2023-03-17coding_update

Coding and Recommendation Updates.

2023-10-30revision

Additional revisions.

2024-01-12coding_updateLatest

Coding and Recommendation Updates.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeNo material changes — informational/reference update

Effective DateJanuary 25, 2024

Next Review DateN/A

Key ActionSupport modifier use with documentation; maintain records and submit correct modifier-to-procedure code combinations to avoid denials.

SourceLink

On This Page

OpenPayer

Modifier Reference Policy

Policy Snapshot

Applicability and Clinical Criteria

Modifier Reference (CPT/HCPCS) — Groups and Guidance

What Providers Must Do

Key Terms

Administrative & Clinical Background

Policy Update Log

Modifier Reference Policy

Policy Snapshot

Applicability and Clinical Criteria

Modifier Reference (CPT/HCPCS) — Groups and Guidance

What Providers Must Do

Key Terms

Cross-References

Administrative & Clinical Background

Policy Update Log