CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Coding and Payment Guidelines for Claims

Governs coding and payment processing rules BCBSRI applies to submitted physician and outpatient hospital claims, aligning with CMS, NCCI, and other national coding standards; affects providers submitting claims to Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and Payment Guidelines for Claims

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing an E&M with a procedure under modifier 25, ensure documentation supports the E&M as significant and separately identifiable to avoid a 50% payment reduction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCCINCCI edits applied

BundledOPPS Addendum B status 'N'

MPFSMPFS indicators

MUEsMUEs followed

ICU addressClaims review address

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Coverage and Payment Criteria

Coverage and payment criteria

Payment determinations for assistant surgeons and co‑surgeons follow Medicare Physician Fee Schedule indicators and BCBSRI contractual rules.

BCBSRI uses Medicare Physician Fee Schedule (MPFS) payment indicators to determine payment eligibility for assistant surgeons and co‑surgeons; these are contractual payment determinations, not medical necessity reviews.

Assistant surgeon payment

Indicator 2: assistant surgeon may be paid; BCBSRI will only pay assistant surgeons for procedures with indicator 2.
Indicator 0: assistant surgeon may be paid with documentation to support medical necessity (note: BCBSRI policy states participating physicians may not bill members separately for assistant surgeon fees outside the approved amount).
Indicator 1: assistant surgeon may not be paid.
Indicator 9: not applicable (service is not surgery).

Co‑surgeon payment

Indicator 2: co‑surgeon permitted and paid; claims submitted by two providers with different specialties will pay without additional specialty documentation.
Indicator 1: co‑surgeon permitted but requires supporting documentation; claim requires review and operative notes must be submitted by each provider at time of claim submission.
Indicator 0: co‑surgeons not permitted for this procedure — claim will deny for co‑surgeon.
Indicator 9: concept does not apply.

Modifier and billing criteria

Modifier usage and billing/payment rules and documentation requirements.

Modifier 25: When a problem‑oriented E&M (99201‑99215) or a general ophthalmological E&M (92002‑92014) is billed with a procedure that has a 0, 10, or 90‑day postoperative period, BCBSRI will reduce payment for the E&M by 50% (effective Oct 15, 2016) unless documentation supports a significant, separately identifiable E&M service.

Documentation requirements for use of modifier 25: the medical record must demonstrate that the complaint could stand alone as a billable service; the purpose of the E&M was to evaluate a complaint separate from the procedure; additional work above typical pre/post procedure care was performed; the visit purpose was other than evaluating/obtaining information needed to perform the procedure; and key components of the selected E&M were performed and documented.

Incorrect modifier submission: If a modifier is submitted incorrectly with the procedure code, BCBSRI will deny the claim line for incorrect use of modifier.

Use of modifier 59 and X‑subsets: Use modifier 59 only when a more descriptive modifier is not available; prefer XE/XS/XP/XU when applicable; do not report modifier 59 and an X‑modifier on the same line.

General coverage stance

Policy stance and limitations

This policy is provided for informational purposes and is not a guarantee of payment; benefits and eligibility are determined by the member's subscriber or employer agreement which supersede this policy.

Providers may not charge members for services determined to be not medically necessary (or non‑covered) unless the member has been informed and agreed in writing in advance; refer to participation agreements for applicable provisions.

Modifier-based payment rules

Payment allowances tied to specific modifiers and indicators.

Modifier code payments and notes: certain modifier indicators denote payment allowances or reductions (examples include GC — service performed in part by a resident; GA/GY — coverage notices; JW — payment allowed for discarded biological drug amount; QK/QX/QY — CRNA/anesthesia direction modifiers pay at 50% when medical direction applies; QZ pays at 100% when no medical direction).

Multiple surgery and percentage rules: specific HCPCS/modifier entries (e.g., F3*/F4*/FA*, RT/LT) include indicators for multiple surgery payment or payment based on a percentage of contracted rate; missing required modifiers may result in claim denial or provider/member liability.

Required modifiers for therapy and other services: some modifiers (GP, GO) are required for services delivered under outpatient therapy plans of care; absence of required modifier may result in denial or provider liability.

Coding Rules and Code Lists

Key modifiers and coding conceptsmixed

Modifier 59	May be used to override certain NCCI indicator edits when appropriate
Global surgery modifiers (24, 25, 57, 58, 78, 79)	Considered exception modifiers relative to CCI edits
Modifiers 80, 81, AS	Assistant surgeon modifiers (80/81 for MD/DO; AS for PA/NP/CNS/RFNA)
Modifier 62	Co-surgeon modifier
Modifier 50, RT, LT	Bilateral reporting modifiers; -50 can be used to report bilateral on one line
Modifier TC	Technical component modifier for services with TC flag

Diagnosis coding specificityICD-10

ICD-10 codes must be coded to the highest degree of specificity as required by CMS/HIPAA.

59-subset modifiersHCPCS

XE/XS/XP/XU

Subsets of modifier 59 defining separate encounter (XE), separate structure (XS), separate practitioner (XP), and unusual non-overlapping service (XU).

Modifier and payment indicator referencemixed

F3*	Left hand, fourth digit; multiple surgery payment indicators and percentage of contracted rate notes
FA*	Left hand, thumb; multiple surgery payment allowed
GC	Service performed in part by a resident under the direction of a teaching physician; payment allowed
GP	Services delivered under outpatient physical therapy plan of care; payment; claim will deny if modifier missing
JW	Amount discarded, not administered to any patient; payment allows for amount of discarded biological drug
QK/QX/QY/QZ	Anesthesia/CRNA modifiers with specified payment percentages and medical direction notes (QK/QX/QY = 50% of allowable when medical direction applies; QZ = 100% of allowable)
TC	Technical component; payment allowed based on percentage of contracted rate
RR	Rental; payment allowed based on percentage of contracted rate

inv-09: Bilateral RVU indicator rules

RVU bilateral indicatorsMedicare MPFS RVU file uses indicators 0,1,2,3,9 to define bilateral treatment and payment; each indicator prescribes how modifiers -50, RT/LT or unit reporting apply.

Indicator 0Modifiers 50/RT/LT do not apply; code represents single side and/or both sides; payment is the lower of total charges or 100% of allowance for a single side.

Indicator 1Second side is treated as a multiple procedure and is reduced; BCBSRI prefers modifier reporting and pays at 150% for -50 or combined RT/LT but payment is the lower of charge or 100% allowance.

Indicator 3Report each side as separate lines using RT/LT; payment based on 100% for each side or total charge if lower (seen primarily in limb imaging and some eye codes).

Indicator 9Bilateral concept does not apply (used for items where bilateral is nonsensical, e.g., certain drugs).

inv-10: Multiple Procedure Indicator rules

Multiple procedure indicators (MULT PROC)BCBSRI follows CMS MPFS MULT PROC values (0,2,3,4,9) from the National Physician Fee Schedule RVU file to determine multiple procedure payment rules.

Value 0No payment adjustment rules for multiple procedures apply.

Value 2Standard payment adjustment rules for multiple procedures apply (highest at 100%, additional eligible procedures at 50% of allowable).

Value 3Special rules for multiple endoscopic procedures within the same family.

Value 4Special rules for the technical component (TC) of diagnostic imaging procedures when billed with another diagnostic imaging procedure in the same family.

Value 9Concept of multiple surgical reductions does not apply.

inv-11: MUE source

MUE sourceBCBSRI follows CMS-published Medically Unlikely Edits (MUEs) for facilities, physicians and durable medical equipment.

Reference locationCMS MUE guidance available on cms.gov; BCBSRI applies those MUEs when processing claims.

ScopeMUEs apply to maximum unit limits and are used across facility, physician and DME claim types.

inv-12: Anesthesia/CRNA payment percentage

CRNA/anesthesia payment percentagesWhen medical direction applies (QK, QX, QY), payment is 50% of the allowable; QZ (CRNA without physician medical direction) is paid at 100% of the allowable.

QKMedical direction of two, three, or four concurrent anesthesia procedures; payment is 50% of allowable.

QXCRNA medical direction by physician; payment is 50% of allowable.

QYMedical direction of one CRNA by an anesthesiologist; payment is 50% of allowable.

QZCRNA service without medical direction of a physician; payment is 100% of allowable.

Provider Billing Actions and Requirements

Prior Authorization

Prior authorization — not applicable

Not applicable

Denial Risk

Incorrect modifier submission will result in denial

If a modifier is submitted incorrectly with the procedure code, BCBSRI will deny the claim line.

Documentation Required

Modifier 25 — documentation required; payment may be reduced

When billing an E&M with a procedure under modifier 25, the member’s medical record must clearly support that the E&M was a significant, separately identifiable service; otherwise the E&M payment may be reduced by 50%.

Documentation must demonstrate the complaint could stand alone as a billable service.
Documentation must show the E&M evaluated a complaint separate from the procedure and that additional work above typical pre/post procedure was performed.
Key components of the appropriately selected E&M must be performed and documented to support separate payment.

Documentation Required

Submit clinical documentation to Individual Consideration Unit for claims review

When a claim requires review, send the clinical documentation to the Individual Consideration Unit of Basic Claims Administration at the address provided by BCBSRI.

Mail to: Individual Consideration Unit of Basic Claims Administration, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

Definitions and Terminology

inv-17: NCCI — National Correct Coding Initiative (NCCI) edits

NCCI adoptionBlue Cross & Blue Shield of Rhode Island follows the National Correct Coding Initiative (NCCI) edits for physician and hospital outpatient claims.

Edit typesNCCI edits include indicator edits (which may be overridden by modifiers such as 59 or X{EPSU}) and '0' indicator edits (which are never correctly reported together).

Exception modifiersGlobal surgery modifiers (24,25,57,58,78,79) and other CMS-listed modifiers are treated as exception modifiers per the CMS file.

inv-18: Global period — Global period designation (000, 010, 090)

Global period designationsCMS assigns global periods of 000, 010, or 090 via the Medicare Physician Fee Schedule RVU files; BCBSRI follows these global period designations to classify major (090) versus minor (000/010) surgical procedures.

Major procedureA 090-day global period designates a major surgical procedure.

Minor procedureA 000- or 010-day global period designates a minor surgical procedure.

inv-19: Technical Component (TC)

Technical Component (TC) usageThe TC modifier should only be appended to codes that have a '1' in the PC/TC field on the National Relative Value File; BCBSRI follows CMS guidelines for correct TC usage.

DefinitionTechnical component identifies the technical portion of a service when a code has separate physician and technical components.

File referenceUse the National Relative Value File (RVU file) PC/TC indicator to determine TC applicability.

inv-20: 59-subset modifiers — XE/XS/XP/XU

59-subset modifiersCMS established four HCPCS -X{EPSU} modifiers (XE, XS, XP, XU) as selective subsets of modifier 59; BCBSRI follows CMS guidance to use these more specific modifiers when appropriate.

XESeparate encounter — service distinct because it occurred during a separate encounter.

XSSeparate structure — service distinct because it was performed on a separate organ/structure.

XPSeparate practitioner — service distinct because it was performed by a different practitioner.

XUUnusual non-overlapping service — service distinct because it does not overlap usual components of the main service.

inv-21: Modifier 25

Modifier 25 definitionModifier 25 denotes a significant, separately identifiable E&M service by the same provider on the same day as a procedure; BCBSRI follows CMS guidance on correct use.

Payment impactEffective October 15, 2016, when a problem-oriented E&M (99201-99215) or ophthalmological E&M (92002-92014) is billed with a procedure having a 0,10, or 90‑day postoperative period, BCBSRI will reduce payment for the E&M by 50% unless documentation supports that the E&M was significant and separately identifiable.

Documentation requirementsMedical record must show the complaint could stand alone, the E&M evaluated a separate complaint, extra work beyond typical pre/post-procedure care was performed, key E&M components were met, and both services are sufficiently documented.

inv-22: GC

GC modifierGC indicates the service was performed in part by a resident under the direction of a teaching physician; BCBSRI allows payment when appropriate.

Payment noteGC entries in the billing information denote that the service was performed in part by a resident and payment is allowed per file indications.

Relation to documentationUse of GC should be consistent with teaching physician/resident documentation requirements to support payment.

inv-23: JW

JW modifier meaningJW denotes amount discarded, not administered to any patient; BCBSRI allows payment for the amount of discarded biological drug as indicated in the billing information.

Payment statusJW is associated with payment allowance entries in BCBSRI's billing reference; payment applies to the discarded portion of biological drugs.

DocumentationClaims using JW should document discarded quantities to justify payment for discarded biological drug amounts.

inv-24: QK/QX/QY

QK/QX/QY payment percentagesWhen medical direction applies (QK, QX, QY), BCBSRI applies a 50% payment of the allowable; QZ (CRNA without physician direction) is paid at 100% of allowable.

QKMedical direction of two, three, or four concurrent anesthesia procedures; payment at 50% of allowable.

QXCRNA medical direction by physician; payment at 50% of allowable.

QYMedical direction of one CRNA by an anesthesiologist; payment at 50% of allowable.

QZCRNA service without medical direction; payment at 100% of allowable.