CurrentEmpire BluecrossPolicy G-06015

Modifier 63 reimbursement

This policy governs reimbursement for services billed with modifier 63 for neonates and infants up to a present body weight of 4 kg for Anthem/Anthem Medicare Advantage members in the listed plan states. It outlines when modifier 63 is allowed, documentation expectations, and nonreimbursable usages.

Policy Summary

PayerEmpire Bluecross

PolicyModifier 63 reimbursement

Policy CodePolicy G-06015

Change TypeClarified / Revised (historical updates)

Effective Date08/28/2020

Next Review Date

Key ActionDocument the neonate's weight clearly in the service report when billing with modifier 63.

SourceLink

POLICY UPDATE CHANGES

Updated minor language; updated title to only include modifier 63; updated definition for modifier 63.

Review approved; no changes (09/06/2024).

Initial approval and effective (01/01/2015).

4 kgweight threshold for modifier 63 applicability

100%reimbursement when modifier valid

multiplepolicy history entries

Coverage Criteria for Modifier 63

Modifier 63 reimbursement criteria

Covered when ALL of the following are met:

Patient is a neonate or infant with present body weight up to 4 kg.

weight threshold applies

Modifier 63 is billed with the procedure code and the neonate weight is documented clearly in the service report.

documentation required for reimbursement

Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate when modifier 63 is valid for the service.

ALL of the following

Policy Summary

PayerEmpire Bluecross

PolicyModifier 63 reimbursement

Policy CodePolicy G-06015

Change TypeClarified / Revised (historical updates)

Effective Date08/28/2020

Next Review Date

Key ActionDocument the neonate's weight clearly in the service report when billing with modifier 63.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ONE OF
- Facility billing.
- With Evaluation and Management (E/M) codes.
- With radiology codes.
- With anesthesia codes.
- With pathology/laboratory codes.
- With modifier 63-exempt codes.
- With medicine codes (other than those appropriate for the modifier).
- In addition to modifier 22 (unusual services) for the same procedure code(s).
- With codes denoting invasive procedures that include neonate or infant in the description (reimbursement already reflects additional work).

Coding and Applicable Codes

ModifiermixedCovered

Modifier 63

Procedures on neonates and infants up to 4 kg may be reported by adding modifier 63

Weight threshold

Weight thresholdUp to a present body weight of 4 kg

Reimbursement basis when modifier valid100% of the applicable fee schedule or contracted/negotiated rate

Documentation requirementNeonate weight must be documented clearly in the service report

Assistant/multiple procedure rulesAssistant surgeon and multiple procedure rules and fee reductions apply when applicable for neonates/infants <4 kg in same operative session

Provider Documentation and Billing Actions

Documentation Required

Documentation requirement and allowance — neonate weight and modifier 63

Anthem Medicare Advantage allows reimbursement for surgery on neonates and infants up to a present body weight of 4 kg when billed with modifier 63 unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. The neonate's present body weight must be documented clearly in the operative report or medical record for the service.

Applies to neonates/infants with present body weight <= 4 kg
Modifier: 63 must be appended to the procedure code
Reimbursement: 100% of applicable fee schedule or contracted/negotiated rate when modifier is valid

Billing Rule

Assistant surgeon / multiple procedures — billing rules and fee reductions

When an assistant surgeon is used and/or multiple procedures are performed on neonates or infants less than 4 kg in the same operative session, assistant surgeon and multiple procedure rules and applicable fee reductions apply. Ensure documentation supports the medical necessity for an assistant surgeon and clearly lists all procedures performed and their operative times as required for billing.

Assistant surgeon rules and fee reductions remain applicable
Multiple procedure reductions apply where appropriate
Document role of assistant surgeon and procedures performed

Definitions

Modifier 63 definition — procedures on neonates and infants up to 4 kg and increased complexity

Definition of Modifier 63Procedures performed on neonates and infants up to a present body weight of 4 kg involve significantly increased complexity and may be reported by adding modifier 63 to the procedure number

ScopeApplies to surgery on neonates and infants with present body weight up to 4 kg for Anthem Medicare Advantage in applicable plan states

Billing noteModifier 63 must be added to the procedure number when the circumstance applies

LimitationReimbursement contingent on documentation of neonate weight and applicable contractual or regulatory requirements