CurrentBlue Cross Blue Shield - TexasPolicy CPCP023

Modifier Reference Policy

Defines appropriate use, billing expectations, and reimbursement considerations for CPT/HCPCS modifiers for Blue Cross and Blue Shield of Texas; applies to providers submitting claims to BCBSTX.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeAnnual review / coding updates

Effective DateApril 19, 2024 (BCBSTX)

Next Review Date

Key ActionProviders must maintain documentation supporting modifier use and submit claims with correct modifier-to-procedure code combinations; corrected claims may be required if denied.

SourceLink

3.0policy version

2024-04-19plan effective date (BCBSTX)

~100+modifiers described or listed (approx.)

Modifier Reference — Scope & Status

This document is the Blue Cross and Blue Shield of Texas Modifier Reference Policy (Policy Number CPCP023), Version 3.0. It serves as a general reference for appending CPT/HCPCS modifiers to procedure codes and outlines billing expectations and reimbursement considerations. The enterprise committee approval date is January 12, 2024 and the plan effective date for BCBSTX is April 19, 2024 (Blue Cross and Blue Shield of Texas Only). The addendum clarifies state‑specific guidance such as the use of modifier SA when a supervising physician bills for non‑surgical services rendered by a PA, APN, or CRNFA; claims will be processed based on provider contracting status.

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Modifiers Listed in Policy Text

Modifiers listed in policy textModifier

22	Increased Procedural Services — not for E/M; requires documentation
23	Unusual anesthesia
24	Unrelated E/M service during postoperative period
25	Significant, separately identifiable E/M on same day as procedure
26	Professional component
TC	Technical component
33	Preventive services
47	Anesthesia by surgeon
50	Bilateral procedure
51	Multiple procedures

1–10 of 83

1/9

Policy is a general reference; inclusion of a modifier in this policy does not guarantee reimbursement. Providers should follow CPT and CMS guidance and applicable plan/provider contract and submit corrected claims if denied for incorrect modifier use. Providers are responsible for submission of accurate documentation and should expect that the plan may request supporting medical records or other documentation and review claims on a case‑by‑case basis.

Documentation, Billing & Prior Authorization Requirements

Documentation Required

Support for modifier use

Providers must maintain documentation supporting modifier use (for example, evidence of substantial additional work for modifier 22, documentation supporting distinct encounter/site/practitioner for XE/XP/XS/XU, or clinical justification for anesthesia modifiers). Documentation may be requested and claims may be reviewed on a case-by-case basis.

Billing Rule

Correct modifier-to-procedure code combination required

Submit claims with the correct modifier-to-procedure code combination; claims containing inappropriate modifier-to-procedure code combinations may be denied and providers must submit corrected claims for reimbursement consideration.

Billing Rule

Modifier ordering when multiple modifiers

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

Billing Rule

Anatomical modifiers required when applicable

Append anatomical modifiers (e.g., LT/RT or E1–E4, FA, TA) when necessary to differentiate site; if a required anatomical modifier is not appended or does not match the appropriate anatomical site, the claim line(s) will deny.

Prior Authorization

Supporting documentation may be requested

BCBSTX reserves the right to request supporting documentation and may review claims per benefit coverage, provider contract language, medical policies, and coding policies; prior authorization may be required per other policies where applicable (see related CPCPs).

Claims may be reviewed on a case-by-case basis and medical records or other documentation may be requested.
Refer to related policies (e.g., CPCP013, CPCP010) for modifier-specific prior authorization or documentation guidance.

Billing Rule

HCPCS Category II and PQRI guidance

Do not submit HCPCS modifiers on claims with PQRI CPT Category II codes; ensure appropriate Category II modifier billing when applicable.

Billing Rule

Modifier SA (BCBSTX addendum) usage

Append modifier SA when the supervising physician bills for non-surgical services rendered by a PA, APN, or CRNFA; append SA on supervising physician claims or on the PA/APN/CRNFA claim when billing with their own NPI. Claims are processed based on provider contracting status.

Policy Dates & Changes

Effective Date: April 19, 2024 (Blue Cross and Blue Shield of Texas Only). Last Review: January 12, 2024. Next Review: Not specified.

April 19, 2024EffectiveLatest

Policy effective (Blue Cross and Blue Shield of Texas only).

01/12/2024Revision

Enterprise committee approval and coding/recommendation updates.

10/30/2023Revision

Additional revisions to the policy.

03/17/2023Revision

Coding and recommendation updates.

05/13/2022Revision

Additional revisions.

04/08/2022Revision

Annual review.

03/31/2021Revision

Annual review.

02/28/2020Revision

Annual review and disclaimer update.

11/27/2018Revision

New policy created.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyModifier Reference Policy

Policy CodePolicy CPCP023

Change TypeAnnual review / coding updates

Effective DateApril 19, 2024 (BCBSTX)

Next Review Date

Key ActionProviders must maintain documentation supporting modifier use and submit claims with correct modifier-to-procedure code combinations; corrected claims may be required if denied.

SourceLink

On This Page

OpenPayer

Modifier Reference Policy

Modifier Reference — Scope & Status

Modifiers Listed in Policy Text

Clinical / Operational Criteria

Documentation, Billing & Prior Authorization Requirements

Defined Terms

Policy Dates & Changes

Modifier Reference Policy

Modifier Reference — Scope & Status

Modifiers Listed in Policy Text

Clinical / Operational Criteria

Documentation, Billing & Prior Authorization Requirements

Defined Terms

Reference — Read With

Policy Dates & Changes