CurrentCareSource GeorgiaPolicy N/A

Modifiers (Reimbursement Modifiers Policy)

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Governance of use, billing, coding, documentation, and review of two-character reimbursement modifiers for CareSource Marketplace lines of business; affects providers submitting claims to CareSource Georgia (Marketplace).

Policy Summary

PayerCareSource Georgia

PolicyModifiers (Reimbursement Modifiers Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2026

Last ReviewApr 22, 2026

Next Review DateAug 1, 2026

Key ActionProviders must maintain and submit documentation to support modifier use; failure to provide accurate and complete documentation may result in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Marketplace: GA, OH, WVApplies to markets

documentation requiredSupport

pre/post-payment reviewReview risk

2-characterModifier format

Modifier Coverage Criteria

Modifier coverage criteria

Covered when the following conditions and requirements are met:

Use of modifiers does not guarantee reimbursement; inclusion of a code in a policy does not imply a right to reimbursement or guarantee payment.

Providers must use the most accurate and appropriate CPT or HCPCS code(s) for the product or service, following industry standards (e.g., NCCI, AMA, AHA, CPT, HCPCS, ICD-10, NDC, DRG).

The use of modifiers must be fully supported by documentation in the medical record and/or office notes; failure to provide accurate and complete documentation may result in denial or incorrect reimbursement.

CareSource may verify modifier use through prepayment or post-payment edits or audits and reserves the right to review submissions for correct coding standards; providers must make supporting information available upon request.

Where a conflict exists between this Policy and the provider contract or Evidence of Coverage, the contract/Evidence of Coverage will govern determinations.

This Policy applies to both participating and nonparticipating providers unless otherwise noted; reimbursement is dependent on member benefits, eligibility, medical necessity, and applicable claims processing rules.

Referenced Code Sets and Coding Rules

Referenced code sets and systemsmixed

CPT	Current Procedural Terminology codes referenced for procedure coding
HCPCS	Healthcare Common Procedure Coding System codes referenced for supplies/services not in CPT
ICD-10	Diagnosis coding referenced (ICD-10-CM/PCS)
NDC	National Drug Codes referenced
DRG	Diagnosis Related Group guidelines referenced

Use of most accurate code

RequirementProviders must use the most accurate and appropriate CPT or HCPCS code(s) for the product or service.

ScopeApplies to providers submitting claims to CareSource Georgia (Marketplace).

ConsequenceClaims billed with inaccurate codes or modifiers may be flagged for prepayment or postpayment coding review.

DocumentationProviders are responsible for submitting accurate documentation to substantiate coding of the claim.

StandardsCareSource reserves the right to review submissions to ensure correct coding standards and guidelines are met.

Authorization, Review, and Provider Responsibilities

Prior Authorization

Authorization, contract precedence, and coding review

This Policy does not ensure an authorization or reimbursement of services; CareSource may use reasonable discretion in interpreting and applying this Policy and may modify it at any time. When conflicts exist, the plan contract (Evidence of Coverage) will control. Provider claims billed with a modifier may be flagged for prepayment or postpayment coding review.

Refer to the plan contract / Evidence of Coverage for final determination when conflicts exist.
Be aware that CareSource may modify the policy and apply discretion on a case-by-case basis.
Claims with modifiers may be subject to prepayment or postpayment review; maintain supporting documentation.

Key Definitions

CPT (Current Procedural Terminology)

DefinitionCurrent Procedural Terminology (CPT) — Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures.

IssuerAmerican Medical Association (AMA).

PurposeProvides standard language for coding and billing medical services and procedures.

UseReferenced for procedure coding and billing on provider claims.

HCPCS (Healthcare Common Procedure Coding System)

DefinitionHealthcare Common Procedure Coding System (HCPCS) — Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes.

ScopeUsed for products, supplies, and services not included in CPT.

IssuerAmerican Medical Association (AMA).

UseReferenced for coding supplies and non-CPT services on provider claims.

Modifier

DefinitionModifier — Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered.

LengthTwo-character code format.

PurposeConveys additional details about how a service or supply was provided (e.g., distinct procedures, multiple procedures, or altered service).

ReviewProvider claims billed with a modifier may be flagged for prepayment or postpayment coding review; documentation must substantiate modifier use.

Policy Summary

PayerCareSource Georgia

PolicyModifiers (Reimbursement Modifiers Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2026

Last ReviewApr 22, 2026

Next Review DateAug 1, 2026

Key ActionProviders must maintain and submit documentation to support modifier use; failure to provide accurate and complete documentation may result in denial.

SourceLink

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Modifiers (Reimbursement Modifiers Policy)

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Sign up for all CareSource Georgia policy alerts

Know when CareSource Georgia releases new policies or updates existing guidance.

Monitor payer policy activity

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Modifier Coverage Criteria

Modifier coverage criteria

Covered when the following conditions and requirements are met:

Use of modifiers does not guarantee reimbursement; inclusion of a code in a policy does not imply a right to reimbursement or guarantee payment.

Providers must use the most accurate and appropriate CPT or HCPCS code(s) for the product or service, following industry standards (e.g., NCCI, AMA, AHA, CPT, HCPCS, ICD-10, NDC, DRG).

Where a conflict exists between this Policy and the provider contract or Evidence of Coverage, the contract/Evidence of Coverage will govern determinations.

Referenced Code Sets and Coding Rules

Referenced code sets and systemsmixed

CPT	Current Procedural Terminology codes referenced for procedure coding
HCPCS	Healthcare Common Procedure Coding System codes referenced for supplies/services not in CPT
ICD-10	Diagnosis coding referenced (ICD-10-CM/PCS)
NDC	National Drug Codes referenced
DRG	Diagnosis Related Group guidelines referenced

Use of most accurate code

RequirementProviders must use the most accurate and appropriate CPT or HCPCS code(s) for the product or service.

ScopeApplies to providers submitting claims to CareSource Georgia (Marketplace).

ConsequenceClaims billed with inaccurate codes or modifiers may be flagged for prepayment or postpayment coding review.

DocumentationProviders are responsible for submitting accurate documentation to substantiate coding of the claim.

StandardsCareSource reserves the right to review submissions to ensure correct coding standards and guidelines are met.

Authorization, Review, and Provider Responsibilities

Prior Authorization

Authorization, contract precedence, and coding review

Refer to the plan contract / Evidence of Coverage for final determination when conflicts exist.
Be aware that CareSource may modify the policy and apply discretion on a case-by-case basis.
Claims with modifiers may be subject to prepayment or postpayment review; maintain supporting documentation.

Key Definitions

CPT (Current Procedural Terminology)

IssuerAmerican Medical Association (AMA).

PurposeProvides standard language for coding and billing medical services and procedures.

UseReferenced for procedure coding and billing on provider claims.

HCPCS (Healthcare Common Procedure Coding System)

ScopeUsed for products, supplies, and services not included in CPT.

IssuerAmerican Medical Association (AMA).

UseReferenced for coding supplies and non-CPT services on provider claims.

Modifier

DefinitionModifier — Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered.

LengthTwo-character code format.

PurposeConveys additional details about how a service or supply was provided (e.g., distinct procedures, multiple procedures, or altered service).

ReviewProvider claims billed with a modifier may be flagged for prepayment or postpayment coding review; documentation must substantiate modifier use.