CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP023

Modifier Reference Policy

Provides guidance on use and billing of CPT/HCPCS modifiers for claims processing and reimbursement; applies to providers submitting claims to BCBSOK under applicable plan documents and provider contracts.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeNo material change

Effective DateMar 30, 2023

Next Review DateN/A

Key ActionSubmit claims with correct modifier-to-procedure code combinations and supporting documentation; corrected claim submission is required if denied for inappropriate modifier use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Version 2.0policy version

Enterprise committeegovernance source

Comprehensive listmodifiers described

11 entriesupdate history

Modifier Coverage and Applicability

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Modifiers may be appended to CPT/HCPCS codes only when the service or procedure is clinically supported for use of modifiers and documentation substantiates the use of the modifier.

A claim must be submitted with the correct modifier-to-procedure code combination; inappropriate combinations may result in denial and will require corrected claim submission with the proper modifier-to-procedure code combination for reimbursement.

Modifiers must not be appended to CPT/HCPCS codes to circumvent NCCI Procedure-to-Procedure (PTP) edits if the service/procedure is not clinically supported for a modifier.

Medical records or other supporting documentation should accompany the claim as needed and the plan may request supporting documentation; claims are subject to case-by-case review.

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

Inclusion of a modifier in this policy does not guarantee reimbursement; the list is not all-inclusive and modifiers may be added or removed with notice.

Surgical and perioperative modifiers

Guidance for appending surgical and perioperative modifiers:

Examples of surgical/perioperative modifier use

Modifier 50 for bilateral procedures on identical anatomic sites; do not bill LT/RT on the same line when using modifier 50.
Modifier 62 when two surgeons of different specialties are required to perform the same procedure during an operative session; both surgeons should append modifier 62 and submit the same procedure and diagnosis codes.
Modifier 66 should be appended when more than two surgeons of different specialties work together under the surgical team concept; submit with supporting documentation describing each surgeon's performance.
Modifiers 54/55/56 (and related) should be used to allocate preoperative/postoperative/surgical care between providers as appropriate.
Modifier 78 should be appended for unplanned return to the operating room during the postoperative period for a related procedure.
Modifiers 73 and 74 for discontinued outpatient/ASC procedures before or after anesthesia, respectively, when due to extenuating circumstances or threat to member well-being.

Modifier claim adjudication criteria

Claims may be denied when modifier requirements are not met; the following adjudication rules apply:

Append required anatomical modifiers to differentiate laterality or specific structure; if a procedure requires an anatomical modifier and it is not appended, the claim will deny.

If a modifier is appended that does not match the appropriate anatomical site for the procedure code, the claim will be denied.

Claims processing systems validate procedure and modifier combinations against required modifier sets by procedure; providers should report modifiers in the appropriate claim fields (box 24D on CMS 1500 or SV101-3 as first modifier for electronic submission).

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

When XE, XP, XS, or XU are appended, documentation must support that the service is distinct (separate encounter, separate practitioner, separate structure, or unusual non-overlapping service) and providers should refer to CMS guidelines for supporting documentation requirements.

Certain HCPCS modifier billing restrictions apply (for example, HCPCS modifiers should not be submitted on claims with PQRI CPT Category II codes); follow Category II modifier billing guidance.

Modifiers QY (medical direction of one CRNA by an anesthesiologist) and QZ (CRNA service without physician medical direction) carry billing responsibility guidance: QY information is billed by an anesthesiologist; QZ information is billed by the CRNA.

Modifier and Code Lists

Sample CPT/HCPCS modifiers (not exhaustive)mixedCovered

22	Increased Procedural Services
25	Significant, separately identifiable E/M service by the same physician
50	Bilateral procedure

Telehealth-related modifiersCPTCovered

95	Synchronous telemedicine service via real-time interactive audio and video
GQ	Via asynchronous telecommunications system
G0	Telehealth services for acute stroke

Provider qualification / drug / DME modifiersHCPCSCovered

HM	Less than bachelor's degree level (ABA services)
HO	Master's degree level (ABA services)
JW	Drug amount discarded/not administered

Anatomical modifiersModifier

E1-E4	Eyelids
FA, F1-F9	Fingers
TA, T1-T9	Toes
LC	Left circumflex coronary artery
LD	Left anterior descending coronary artery
LM	Left main coronary artery
LT	Left
RI	Ramus intermedius
RC	Right coronary artery
RT	Right

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inv-08: Modifier-to-procedure validity

RequirementClaims must be submitted with the correct modifier-to-procedure code combination; inappropriate combinations may be denied and require a corrected claim for reimbursement.

Clinical supportAppend modifiers only when the service or procedure is clinically supported for use of modifiers and documentation substantiates use.

No circumventionDo not append modifiers to circumvent NCCI Procedure-to-Procedure (PTP) edits when the service is not clinically supported.

DocumentationMedical records or other supporting documentation should accompany the claim; the plan may request supporting documentation and may review claims case-by-case.

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

Provider Responsibilities and Billing Guidance

Documentation Required

Documentation and Claim Review — providers must submit accurate documentation and may be asked for supporting docs; claims subject to review

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims using HIPAA-approved code sets and to follow industry standard coding guidelines (e.g., UB Editor, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI). Claims are subject to code edit protocols and may be reviewed for benefit coverage, contract language, medical and coding policies, and coding software logic. Upon request, the plan may require supporting documentation; providers are urged to submit medical records or other documentation to ensure appropriateness of claim reimbursement.

Claims are subject to review and may be denied if documentation or coding is incorrect
Submit corrected claims with appropriate modifier-to-procedure combinations when required
If billing with multiple modifiers, list the modifier that will impact reimbursement first

Denial Risk

Denial Risk for Incorrect Modifiers — claims with inappropriate modifier-to-procedure combinations may be denied; corrected claims process

Modifiers may be appended to CPT/HCPCS codes only when clinically supported. Do not append modifiers to circumvent NCCI Procedure-to-Procedure (PTP) edits. Claims containing inappropriate modifier-to-procedure code combinations may be denied; a corrected claim with the correct modifier-to-procedure combination will be necessary for reimbursement consideration. The plan reserves the right to request supporting documentation and to review claims case-by-case.

Modifiers should reflect the clinical circumstance and be supported by documentation
Inappropriate modifier-to-procedure combinations can result in claim denial
Corrected claims must be submitted when initial submissions are denied for modifier issues

Billing Rule

Modifier append rules and billing responsibility — examples when to append QY/QZ and related anesthesiology rules

Append QY when one CRNA or Anesthesia Assistant (AA) is medically directed by an Anesthesiologist; the anesthesiologist bills the modifier information. Append QZ when a CRNA provides service without physician medical direction; the CRNA bills the modifier information. RR is appended for DME rentals (one unit billed per monthly period unless classified as a daily rental). UE is appended for used DME equipment. SH reports a second concurrently administered infusion therapy; SJ denotes third-or-more concurrent infusion therapy and services submitted with SJ will not be reimbursed. When billing multiple modifiers, order them so the modifier that impacts reimbursement is listed first.

QY — Medical direction of one CRNA by an Anesthesiologist; append when applicable; billed by anesthesiologist
QZ — CRNA service without medical direction by a physician; append when applicable; billed by CRNA
RR — Rental for DME; append for rentals (one unit per monthly period unless daily rental)
UE — Used durable medical equipment; append when applicable
SH — Second concurrently administered infusion therapy; append to report second concurrent infusion
SJ — Third or more concurrently administered infusion therapy; services with SJ will not be reimbursed

Documentation Required

Distinct service modifiers require supporting documentation — XE/XP/XS/XU usage conditions

Distinct service modifiers (XE, XP, XS, XU) require supporting documentation demonstrating the distinctness of the service. Documentation must support that the service meets the specific condition for the modifier: separate encounter (XE), separate practitioner (XP), separate structure (XS), or unusual non-overlapping service (XU). Follow CMS guidelines when appending these modifiers; the plan may request medical records to substantiate use of the modifier.

XE — Separate encounter: documentation must show the service occurred during a separate encounter
XP — Separate Practitioner: documentation must show the service was performed by a different practitioner
XS — Separate Structure: documentation must show the service was performed on a separate organ/structure
XU — Unusual non-overlapping service: documentation must show the service does not overlap usual components of the main service
Refer to CMS guidelines for application and supporting documentation expectations

Key Terms and Modifier Definitions

inv-13: Modifier

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

PurposeDenote additional information about the service rendered; some modifiers affect reimbursement while others are informational.

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

inv-14: Modifier-to-procedure code combination

DefinitionThe specific pairing of a modifier with a procedure code that must be clinically supported and appropriately submitted to avoid claim denials.

Adjudication impactClaims may be denied if an inappropriate modifier-to-procedure code combination is submitted; a corrected claim with the proper combination is required for reimbursement.

Documentation requirementMedical records or other documentation should accompany the claim to ensure appropriateness of reimbursement; the plan may request supporting documentation.

inv-15: Medical direction of one CRNA by an Anesthesiologist — QY

ModifierQY

MeaningMedical direction of one certified registered nurse anesthetist (CRNA) by an Anesthesiologist.

When to appendAppend when one CRNA or Anesthesiologist Assistant (AA) is under the direction of the Anesthesiologist.

Billing responsibilityModifier information is billed by an Anesthesiologist (MD).

inv-16: CRNA service without medical direction by a physician — QZ

ModifierQZ

MeaningCRNA service: without medical direction by a physician.

When to appendAppend when a CRNA provides the service without medical direction by a physician.

Billing responsibilityModifier information is billed by the CRNA.

inv-17: Rental (DME rentals billed per monthly period unless daily) — RR

ModifierRR

MeaningRental.

When to appendAppend modifier for durable medical equipment (DME) rentals.

Unit of serviceOne unit of service is billed per monthly period unless classified as a daily rental.

inv-18: Second concurrently administered infusion therapy — SH

ModifierSH

MeaningSecond concurrently administered infusion therapy.

When to appendAppend modifier to report a second concurrently administered infusion therapy.

inv-19: Third or more concurrently administered infusion therapy (services with SJ will not be reimbursed) — SJ

ModifierSJ

MeaningThird or more concurrently administered infusion therapy.

Reimbursement ruleServices submitted with modifier SJ will not be reimbursed.

inv-20: Used durable medical equipment — UE

ModifierUE

MeaningUsed durable medical equipment.

When to appendAppend modifier for used DME equipment.