CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Coding and Payment Guidelines (Coding and payment rules for claims)

Governance of coding and payment rules for claims submitted to Blue Cross & Blue Shield of Rhode Island (BCBSRI), applicable to Medicare Advantage and commercial products and providers submitting physician and outpatient hospital claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and Payment Guidelines (Coding and payment rules for claims)

Policy CodePolicy N/A

Change TypeMinor/Reference update

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionFile claims with correct modifiers and separate claim lines when using multiple site-of-service modifiers to avoid denial or misprocessing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-daymajor surgical global period

100% / 50%multiple procedure payment

100% / 60%radiology multiple-service payment

QuarterlyOPPS updates

Reference-onlydocument applicability

Coverage and Payment Criteria

Coding and payment criteria

BCBSRI adopts CMS and national coding/payment standards and applies specific payment determinations using CMS indicator files and CPT guidelines.

BCBSRI follows National and Regional CMS and other national coding standards (e.g., CPT) for correct coding and payment determinations.

NCCI edits are applied to physician and hospital outpatient claims; '0' indicator edits never reported together; '1' indicator edits may be overridden by an allowed modifier (e.g., 59 or X{EPSU} modifiers).

NCCI exception modifiers include anatomic modifiers (E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI), global surgery modifiers (24,25,57,58,78,79), and others (27,59,91,XE,XS,XP,XU).

BCBSRI follows CMS OPPS for outpatient hospital services: codes with status indicator 'N' are covered but not separately reimbursed (bundled); packaged code updates applied quarterly; drugs billed with surgeries are generally bundled except chemodenervation codes (64600-64681) which are separately reimbursed.

BCBSRI follows the CMS Physician Fee Schedule (PFS RVU files) for global period, assistant surgeon, co-surgery, bilateral surgery, and multiple procedure reduction rules.

Assistant surgeon payment: BCBSRI will only pay assistant surgeons for procedures with an assistant-surgeon indicator '2' on the PFS RVU file; indicators 0,1,9 do not permit payment. This is a contractual payment determination, not a medical necessity review.indicator = 2

Co-surgeon payment: BCBSRI uses MPFS indicators to determine payment: indicator 0 denies co-surgeon payment; indicator 1 requires claim review and operative notes; indicator 2 permits payment (especially when submitted by two providers of different specialties); indicator 9 does not apply. Operative notes required per indicator rules.

Bilateral surgery: BCBSRI adopts CMS bilateral payment policies but will follow CPT guidance when CMS and CPT conflict. The PFS 'Bilat Surg.' indicators (0,1,2,3,9) determine appropriate modifier use and payment handling.

Multiple procedure (surgical) reductions: BCBSRI follows CMS MULT PROC indicators; the highest-priced surgical procedure is paid at 100% and additional separate procedures (not bundled or add-ons) are paid at 50% unless otherwise exempt.100% then 50%

Diagnostic imaging multiple-service payment: for radiology services with Diagnostic Family indicator 88 filed with modifier TC or global, the highest-allowed service is paid at 100% and subsequent services at 60%; no reduction applies when modifier 26 is present.100% then 60%

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

Billing and modifier coverage criteria

Coverage and payment rules summarized from BCBSRI billing guidance in this section.

For radiology services identified with Diagnostic Family indicator 88 and filed with modifier TC or global, BCBSRI pays the highest-allowed service at 100% and subsequent services at 60%; no reduction applies when modifier 26 is present.100% then 60%

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

Modifier 25 rule: E&M codes (99201-99215) or ophthalmology codes (92002-92014) billed with a procedure having 0/10/90 day global period will have the E&M payment reduced by 50% (effective Oct 15, 2016); E&M services reimbursed under per diem/all-inclusive arrangements are not impacted.50% reduction

Use of modifier 59 should be limited; when more specific X{EPSU} modifiers (XE, XS, XP, XU) apply they should be used instead and should not be reported together with modifier 59.

Coverage Applicability

This document is a reference and does not establish coverage criteria.

Not applicable as this policy is a reference document and not a coverage policy.

Coding, Modifiers, and Payment Notes

NCCI exception modifiersModifier

59	Distinct procedural service (use limited; prefer X{EPSU} when applicable).
XE	Separate encounter - service distinct because it occurred during a separate encounter.
XS	Separate structure - service distinct because it was performed on a separate organ/structure.
XP	Separate practitioner - service distinct because it was performed by a different practitioner.
XU	Unusual non-overlapping service - distinct because it does not overlap usual components of the main service.
24	Unrelated evaluation and management service during postoperative period.
25	Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure.
57	Decision for surgery.
58	Staged or related procedure during the postoperative period.
78	Unplanned return to the operating room for a related procedure during the postoperative period.

1–10 of 44

1/5

Physician Fee Schedule and modifier/payment rulesModifier

80	Assistant surgeon — payment indicator applies where allowed.
81	Minimum assistant surgeon — payment indicator applies where allowed.
AS	Assistant surgeon for mid-levels — informational; BCBSRI pays assistant surgeon only when procedure has indicator 2.
62	Two surgeons (co-surgery).
50	Bilateral procedure modifier.
RT	Right side.
LT	Left side.
51	Multiple procedures — modifier 51; CMS/BCBSRI follow MPPR rules where applicable.

Technical Component (TC)ModifierCovered

TC	Technical component identifier — use only on codes with PC/TC = 1 on the National Relative Value File.

Distinct procedural service modifiersModifierCovered

59	Distinct procedural service (see X{EPSU} alternatives).
XE	Separate Encounter.
XS	Separate Structure.
XP	Separate Practitioner.
XU	Unusual Non-Overlapping Service.

340B drug modifiersModifierCovered

JG	Indicates drug was acquired outside the 340B program (used by non-340B providers when required by CMS informational reporting).
TB	Indicates drug or biological was acquired with 340B drug pricing program discount (used by select 340B entities).

Selected HCPCS Modifiers and payment notesModifier

AS	Assistant surgeon for mid-levels — BCBSRI pays assistant surgeon only when procedure has indicator 2; claims review as required by payer/contract.
RT	Right side — used for laterality and may affect multiple surgery payment when applicable.
LT	Left side — used for laterality and may affect multiple surgery payment when applicable.
TB	340B informational modifier — indicates drug acquired under 340B program; TB is informational per CMS for select entities.

Filing Requirements and Provider Actions

Prior Authorization

Prior authorization — Not applicable

Not applicable

Denial Risk

Incorrect modifier will result in claim-line denial

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

Definitions and Modifier Guidance

National Correct Coding Initiative (NCCI)

DefinitionNCCI edits are code-pair edits designed to prevent reporting of codes that should not be reported together.

Indicator '0''0' indicator edits are never correctly reported together (codes should not be billed together).

Indicator '1''1' indicator edits may be overridden by an appropriate modifier (commonly modifier 59 or an X{EPSU} modifier).

Exception modifiersBCBSRI considers anatomic modifiers (E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI), global surgery modifiers (24,25,57,58,78,79) and other modifiers (27,59,91,XE,XS,XP,XU) as exceptions per the CMS file.

Technical Component (TC)

Definition

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and Payment Guidelines (Coding and payment rules for claims)

Policy CodePolicy N/A

Change TypeMinor/Reference update

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionFile claims with correct modifiers and separate claim lines when using multiple site-of-service modifiers to avoid denial or misprocessing.

SourceLink

On This Page

BCBSRI follows CMS split/shared E/M rules (effective Jan 1, 2022): the practitioner who provides the substantive portion bills the visit; documentation must identify both individuals and the substantive provider must sign and date the medical record; applicable modifiers include FQ, FR, FS, FT.

For CY2023, report 340B drug modifiers per CMS: TB for certain OPPS‑exempt entities and JG for other 340B providers (informational reporting requirement).

File multiple site-of-service modifiers on separate claim lines

Claims filed using multiple site-of-service modifiers must be submitted on separate claim lines; claims with these modifiers on the same line will not process correctly.

Documentation Required

Submit clinical documentation for claims requiring review

When a claim requires review, the clinical documentation must be sent to BCBSRI's Individual Consideration Unit of Basic Claims Administration at the address provided.

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

Technical Component (TC) identifies the technical component of services that combine physician (professional) and technical components.

Modifier UsageUse modifier TC to report the technical component of a service.

PC/TC field requirementThe TC modifier should only be appended to codes that have a '1' in the PC/TC field on the National Relative Value file.

Assistant Surgeon

DefinitionAssistant surgeon modifiers define reporting and relative payment responsibilities: Modifier 80 (assistant surgeon MD/DO majority), Modifier 81 (assistant MD/DO less than majority), AS (assistant by PA/NP/CNS/RFNA).

Payment responsibilityPrimary surgeon reports procedures without modifier at full fee; assistant appends assistant modifier and is paid at a reduced fee or per contracted percentage.

Payment condition (BCBSRI)BCBSRI will only pay for an assistant surgeon for procedures that have an indicator '2' (assistant surgeon may be paid) on the RVU file.

Co-Surgeon

DefinitionCo-surgeon (modifier 62) indicates two surgeons performing distinct, separate parts of the same procedure, commonly when one performs the approach and the other the definitive procedure.

Documentation requirementTwo distinct operative notes are required and they must not overlap to support co-surgery billing.

Modifier applicationModifier 62 should be appended to only one primary procedure code and its associated add-on codes; if the second surgeon assists rather than performs a distinct part, assistant modifiers (81 or 82) apply.

TermTC (Technical Component).

PurposeIdentifies the technical component of services that are composed of physician and technical components.

ApplicabilityUse TC only when the PC/TC field on the National Relative Value file equals 1 for the code.

XE/XS/XP/XU

DefinitionX{EPSU} modifiers (XE, XS, XP, XU) are CMS-established specific subsets of modifier 59 defining distinct procedural services by encounter, structure, practitioner, or non-overlap.

When to useUse the most specific -X{EPSU} modifier when appropriate; CPT guidance states modifier 59 should be limited and not used when a more specific modifier is available.

Do not combineIt is incorrect to report a -X{EPSU} modifier together with modifier 59 on the same line; they are mutually exclusive per CMS guidance.

Split/shared E/M

DefinitionA split (or shared) E/M visit is a facility visit provided by a physician and/or an NPP in the same group, billed by the practitioner who provides the substantive portion of the visit.

Substantive portionFor 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.

ModifiersModifiers to identify split/shared visits include FS, FT, FQ, FR (and FQ for audio-only where applicable); policy does not apply to office visits (POS 11).

Modifier 78

DefinitionModifier 78: Unplanned return to the operating room by the same physician for a related procedure during the postoperative period.

Payment notesModifier 78 payment handling may include application of a global percentage of payment or payment based on a percentage of contracted rate as noted in BCBSRI billing information.

Use caseAppend modifier 78 when an unplanned related return to the OR by the same physician occurs during the postoperative period.

Modifier 79

DefinitionModifier 79: Unrelated service or procedure by the same physician during the postoperative period.

Payment notesModifier 79 payment handling may include application of global payment rules or payment based on a percentage of contracted rate per BCBSRI billing information.

Use caseReport modifier 79 when the service/procedure is unrelated to the original procedure during the postoperative period.

Modifier GY

DefinitionModifier GY indicates an item or service is not covered.

Claim outcomeClaims reported with modifier GY will be not covered per BCBSRI guidance.

Use caseApply modifier GY when the service is statutorily non-covered or otherwise not covered by the plan.

Modifier KX

DefinitionModifier KX documents that requirements specified in the medical policy have been met.

Payment implicationWhen KX is present and policy requirements are met, payment is allowed per the policy conditions.

Use caseAppend KX when the claim meets specified medical policy requirements to indicate payment eligibility.