CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Coding and Payment Guidelines Modifiers

Governance of coding and payment rules BCBSRI applies to Medicare Advantage and commercial claims, describing modifier use, bundling, surgeon/assistant/co-surgeon payment rules, bilateral and multiple-procedure reductions, and adherence to CMS and CPT guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Coding and Payment Guidelines Modifiers

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date11|11 2011

Next Review DateN/A

Key ActionAppend modifier TC only to codes with a '1' in the PC/TC field per NRV file.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCCI/OPPS/PFSExternal CMS coding files/guidance the policy follows

60.4%Diagnostic radiology subsequent services paid at

50%E/M payment reduction example

Jan 1, 2022Split/shared E/M refined effective

Coverage and Payment Criteria

Coverage and payment criteria

BCBSRI adheres to CMS and CPT coding/payment files; specific numeric indicators on CMS RVU files drive payment rules for assistants, co-surgeons, bilateral services, multiple-procedure reductions, and bundled outpatient services.

BCBSRI follows national CMS and CPT coding/payment guidance (NCCI, OPPS, PFS RVU files) when applying coverage and payment rules.

National Correct Coding Initiative (NCCI) edits are applied; some edits may be overridden by allowed modifiers (e.g., modifier 59 or CMS X-modifiers); %0 edits are never reported together.

Outpatient hospital codes with OPPS status indicator 'N' are covered but not separately reimbursed (bundled) per CMS OPPS; BCBSRI updates packaged code lists quarterly to align with CMS.

Assistant surgeon payment: BCBSRI uses assistant surgeon indicators on the Medicare PFS RVU file (0,1,2,9). Payment is made only for procedures with indicator = 2; participating physicians may not balance-bill members for assistant surgeon fees when indicator = 0,1, or 9.

Co-surgeon payment: BCBSRI follows PFS RVU file indicators (0,1,2,9). Indicator 2 permits payment for two providers (typically different specialties); indicator 1 requires operative notes and claim review; indicator 0 does not permit co-surgeon payment; indicator 9 does not apply.

Bilateral surgery payment uses the PFS 'Bilat' indicators (0,1,2,3,9) to determine treatment: indicator 1 treats second side as multiple-procedure reduction (use -50 or RT/LT with payment conventions described), indicator 2 is inherently bilateral and paid at 100% for the bilateral descriptor, indicator 3 (report each side RT/LT) is paid at 100% each, and indicator 9 is not applicable.

Multiple procedure reductions: BCBSRI follows CMS multiple procedure (MULT PROC) indicators on the PFS RVU file. The highest-valued eligible procedure is reimbursed at 100%; additional separate procedures by the same physician on the same date are typically reimbursed at reduced percentages (commonly 50%) unless exempt (add-on codes or 51-exempt as defined by CPT/CMS).

Diagnostic imaging (MPPR) reductions: for multiple radiology services by same provider/group on same date, the first service is paid at 100% and subsequent services are paid at 60.4%; no reduction applies when professional component (modifier 26) is appended.

Technical component (TC): append modifier TC only to codes with a '1' in the PC/TC field on the National Relative Value File; BCBSRI follows CMS guidance for TC usage.

Coverage and billing criteria

BCBSRI's coverage and payment processing stance follows CMS rules for bundling, MUEs, modifier usage and split/shared E/M; specific modifiers affect reimbursement and may trigger claim review or denial.

OPPS bundling: Codes with OPPS status indicator 'N' are covered but packaged (not separately reimbursed); BCBSRI updates packaged codes quarterly per CMS OPPS.

MUEs / Maximum Unit Limits: BCBSRI follows CMS-published Medically Unlikely Edits (MUEs) for facilities, physicians and DME.

Modifier 25: Indicates a significant, separately identifiable E/M by the same provider on the same day as a procedure. For certain E/M codes billed with procedures that have 0/10/90-day global periods, payment may be reduced (example: effective Oct 15, 2016 a 50% reduction for specified E/Ms); documentation must support that both services are significant, separate, and sufficiently documented.

Modifier 24: Use for an unrelated E/M service during the postoperative period; the reason for the visit must be unrelated to the original procedure and documentation must support medical necessity for a separate E/M.

Split/shared E/M visits (facility setting): A modifier is required (FR, FQ, FS, FT as appropriate). Documentation must identify both individuals who performed the visit and the individual who provided the substantive portion must sign and date the medical record. The substantive portion is defined by history, exam, MDM, or time as per CMS guidance.

Distinct procedural service modifiers: Use CMS X{EPSU} modifiers (XE, XS, XP, XU) in lieu of modifier 59 when applicable; use of modifier 59 should be limited per CMS guidance.

Billing consequences

Incorrect or missing modifiers may result in claim denials or payment adjustments.
Certain modifiers have defined reimbursement impacts (examples in CMS RVU guidance include multiple-procedure reductions, payment percentages for modifiers 52/53/73/74, assistant/co-surgeon impacts, and others); follow CMS/BCBSRI processing rules for payment calculation.

Technical Component (TC): Append TC only to codes with PC/TC = 1 on the NRV file; BCBSRI follows CMS guidance for TC modifier usage.

Modifier payment stances

Modifier-specific payment stance and notes

GA — Waiver of liability statement issued as required by payer policy; informational/payment note. Claims may deny as member liability when applicable.

GC — Service performed in part by a resident under the direction of a teaching physician; informational/payment note; payment allowed per rules when applicable.

GP / GO — Services delivered under outpatient PT/OT plans of care; informational/payment notes and may affect payment when modifier missing or as required.

GX — Notice of liability issues (voluntary); informational/payment note but may result in member liability or denial depending on circumstances.

GY — Item or service is not covered; claims with GY will be not covered.

KS — Indicates requirements specified in the medical policy have been met; payment allowed when medical criteria are met.

TU — Special payment rate / prolonged services payment; claims with TU require review and clinical documentation must be submitted to BCBSRI's Individual Consideration Unit.

SA — Nurse practitioner rendering services in collaboration with a physician; payment may be reduced (example: reduced 15% of contracted rate per processing notes).

Code Lists, Modifiers, and Coding Notes

Modifiers (neutral)Modifier

50	Bilateral procedure
RT	Right side
LT	Left side
-50	Bilateral procedure (alternate format)
80	Assistant surgeon
81	Minimum assistant surgeon
AS	Medically necessary assistant surgeon
TC	Technical component
26	Professional component
51	Multiple procedures

Technical Component (TC)Modifier

TC	Technical component — identifies technical portion of a combined service; BCBSRI follows CMS guidelines and TC should only be appended when the PC/TC field on the NRV file indicates technical component (PC/TC = 1).

Distinct Procedural Service ModifiersModifier

XE	Separate Encounter
XS	Separate Structure
XP	Separate Practitioner
XU	Unusual Non-Overlapping Service
59	Distinct procedural service (use limited; prefer X{EPSU} when applicable)

Common Modifiers and Reimbursement ImpactModifier

25	Significant, separately identifiable E/M service — effective Oct 15, 2016 certain E/Ms billed with procedures having 0/10/90-day globals reduced by 50% per policy
26	Professional component — payment allowed based on percentage of contracted rate
50	Bilateral procedure — payment made at 150% of base code fee (per policy)
51	Multiple procedures — primary reimbursed at 100%; subsequent at 50% (other than add-on or 51-exempt codes)
52	Reduced services — payment made at 80%
53	Discontinued services — payment made at 50% (effective 10/1/2014)
54	Surgical care only — percentage per CMS
55	Postoperative care only — percentage per CMS
57	Decision for surgery — global payment rules apply
58	Staged/related procedure — global percentage payment

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Modifiers with Payer NotesModifier

FR	Split/shared or audio-only supervision indicators — file on separate claim lines; informational
FS	Split/shared E/M visit — informational
FT	Unrelated E/M during postoperative period — informational
GA	Waiver of liability statement on file — payment/denial per policy
GC	Resident involved under teaching physician — payment per contracted rate
GO	OT plan of care — payment; claim may deny if missing
GP	PT plan of care — payment; claim may deny if missing
LT	Left — informational; impacts payment as percentage of contracted rate when applicable
RT	Right — informational; impacts payment as percentage of contracted rate when applicable
TC	Technical component — payment allowed based on percentage of contracted rate; clinical documentation may be required for claims needing review

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Billing, Documentation, and Provider Requirements

Prior Authorization

Not applicable

Documentation Required

Split (shared) E/M visits

Split/shared E/M visits require a modifier on the claim to identify the service and support program integrity. The medical record must identify both individuals who performed the visit and the individual who provided the substantive portion must sign and date the record. The substantive portion is the history, physical exam, medical decision‑making, or more than half of the total time (per CMS guidance effective Jan 1, 2022; anticipated refinement for 2023 to define substantive portion as >50% of total time). This policy applies to facility settings only (not to office visits, POS 11).

FR – Supervising practitioner present via two‑way audio/video communication technology
FQ – Service furnished via audio‑only communication technology
FS – Split (or shared) evaluation and management visit
FT – Unrelated E/M visit during a postoperative period or on the same day as a procedure (report when unrelated)

Terminology and Definitions

inv-18: National Correct Coding Initiative (NCCI)

DefinitionNational Correct Coding Initiative (NCCI) are edits to prevent inappropriate reporting of code pairs that should not be reported together.

Edit typesNCCI edits include %0 indicator edits (never reported together) and <1 indicator edits (may be overridden by an allowed modifier).

Exception modifiersBCBSRI follows CMS exception modifier indicators; listed modifiers include global surgery modifiers (24,25,57,58,78,79) and others (27,59,91,XE,XS,XP,XU).

inv-19: TC

Technical component (TC)The TC modifier identifies the technical component of a service that has separate physician and technical components.

When to appendAppend TC only to codes with a '1' in the PC/TC field on the National Relative Value File (NRV/PFS RVU).

BCBSRI stanceBCBSRI follows CMS guidance for correct usage of the TC modifier.

inv-20: Global period

Global period valuesGlobal periods are designated as 0, 10, or 90 days for procedures on the Medicare PFS RVU file.

Major vs minor90-day global = major surgical procedure; 0- or 10-day global = minor surgical procedure.

UseGlobal period designations determine whether post-operative services are included in the global package and affect separate E/M reporting/payment.

inv-21: TC

TC usage noteUse the TC modifier only for codes identified with a '1' in the PC/TC field on the National Relative Value File; applies to services with separate physician and technical components.

PurposeTC identifies the technical component when a service is divisible into physician work and technical aspects.

BCBSRI adherenceBCBSRI follows CMS guidance for correct TC modifier usage.

inv-22: X{EPSU} modifiers

X{EPSU} modifier setCMS established XE, XS, XP and XU as specific subsets of modifier 59 to define distinct procedural services (Separate Encounter, Separate Structure, Separate Practitioner, Unusual Non-Overlapping Service).

Preference over 59CPT/CMS guidance states modifier 59 should not be used when a more descriptive X{EPSU} modifier is available; use X{EPSU} modifiers when appropriate.

BCBSRI stanceBCBSRI follows CMS guidelines regarding use of the X{EPSU} modifiers and limits use of modifier 59 when a specific X modifier applies.

inv-23: Split/shared E/M

Definition of split/shared E/MA split (shared) E/M visit in the facility setting is provided by a physician and/or non-physician practitioner (NPP) in the same group and is billed by the practitioner who provides the substantive portion of the visit.

Substantive portion and documentationFor 2022 the substantive portion may be history, physical exam, medical decision-making, or more than half of total time; documentation must identify both individuals and the substantive provider must sign and date the record.

Modifier requirementA modifier (FR, FQ, FS, FT as appropriate) is required on the claim to identify split/shared E/M services in facility settings.

inv-24: Informational

Informational vs payment noteModifiers may be flagged as informational only or as payment notes depending on the modifier (e.g., GA, GC, GP, GO, GX, GY).

Claim impactAn informational flag may still affect adjudication (e.g., missing modifier can lead to denial or member liability depending on modifier context).

ExamplesGA may indicate waiver of liability (payment note); GY indicates an item or service is not covered (informational/payment note).

inv-25: Individual Consideration Unit

Recipient for documentation when review requiredClinical documentation for claims requiring review must be sent to: Individual Consideration Unit of Basic Claims Administration, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

When requiredSubmission is required when modifiers or indicators cause the claim line to be flagged for review (e.g., TU or other review-triggering indicators).

Policy roleThe Individual Consideration Unit is BCBSRI's recipient for clinical documentation when adjudication requires additional review.

OpenPayer

Payment Policy Coding and Payment Guidelines Modifiers

Coverage and Payment Criteria

Code Lists, Modifiers, and Coding Notes

Billing, Documentation, and Provider Requirements

Terminology and Definitions

Publication and Revision History

Payment Policy Coding and Payment Guidelines Modifiers

Coverage and Payment Criteria

Code Lists, Modifiers, and Coding Notes

Billing, Documentation, and Provider Requirements

Terminology and Definitions

Publication and Revision History

Referenced Policies and Cross-References