CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Use of CPT and HCPCS Modifiers Affecting Claims Processing and Reimbursement

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This policy governs which CPT and HCPCS modifiers Neighborhood Health Plan of Rhode Island accepts and how certain modifiers affect claims processing and reimbursement for Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse of CPT and HCPCS Modifiers Affecting Claims Processing and Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage, and authorization criteria and be prepared to provide medical records upon request to substantiate billed services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Use of CPT and HCPCS Modifiers Affecting Claims Processing and Reimbursement

Customize your policy alerts

Sign up for all Neighborhood Health Plan of Rhode Island policy alerts

Know when Neighborhood Health Plan of Rhode Island releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse of CPT and HCPCS Modifiers Affecting Claims Processing and Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage, and authorization criteria and be prepared to provide medical records upon request to substantiate billed services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120%reimbursement % for 22/23

100%reimbursement % for 25/91/XU/79

69%reimbursement % for 54/58/78

30%reimbursement % for 26 (PC)

13.6%reimbursement % for AS

CPT/ICD-10/HCPCScoding systems required

Modifier acceptance and coverage rules

inv-01: Modifier acceptance and documentation criteria

General requirements for modifier acceptance, documentation, and reimbursement:

Neighborhood accepts all standard CPT and HCPCS modifiers in accordance with the appropriate CPT or HCPCS procedure code(s).

Absence of an appropriate modifier or use of an inappropriate modifier may result in claim denial.

Providers are reimbursed according to Neighborhood's contracted rates; claims are subject to claim edits.

Medical notes or medical records may be required for certain modifiers to substantiate medical necessity; Neighborhood reserves the right to request medical records for any service billed and follows CMS documentation standards.

Documentation must support the service(s) billed and the medical necessity of the service(s).

Non-covered modifiers are addressed in Neighborhood's Non-Covered Payment Policy (referenced in this policy).

Policy applies to the scope described in the policy and is informational only; claim payments remain subject to benefit coverage, member eligibility, edits, authorizations, contracts, and regulations.

inv-02: Surgical modifier rules

Surgical and assistant surgeon modifier rules and documentation expectations:

ALL of the following

Services that do not require a return to the operating room cannot be billed with modifier 78.
The physician must bill the procedure code that best describes the surgical procedure performed; the initial procedure code should not be billed unless the exact identical procedure is performed again.
When a procedure with a 000 global period is performed to treat complications, the follow-up procedure is reimbursed at 100%.
Full payment is allowed for treatment of complications by another physician or surgeon; these services should not be billed with a 78 modifier.

Modifiers 62 and 66 indicate co-surgeons or a surgical team; appropriate documentation establishing medical necessity for two surgeons or a team is required; services without indication for a co-surgeon or team will be denied.

inv-03: Coverage-related statements and requirements

Statements that affect coverage, payment processing, and provider responsibilities:

This payment policy is informational only and is not a guarantee of reimbursement; claim payments are subject to Neighborhood benefit coverage, member eligibility, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations.

Neighborhood reserves the right to request medical records for any service billed; documentation must support the services billed and the medical necessity of the services; Neighborhood follows CMS documentation standards.

Providers must submit complete claims for payment within contractually determined timely guidelines and use AMA CPT, ICD-10-CM, and HCPCS Level II coding standards.

All services billed to Neighborhood for reimbursement are subject to audit.

Commercial plan members may be responsible for coinsurance, copays, and deductibles based on plan selection (member cost sharing may apply).

Accepted modifiers, coding systems, and reimbursement adjustments

Accepted modifiers and examples of reimbursement adjustmentsModifier

22	Unusual procedural services; documentation required; reimbursement 120%.
23	Unusual anesthesia; reimbursement 120%.
24	Post-surgical visits unrelated to surgery may be reimbursed separately.
25	Significant, separately identifiable E/M service same day as procedure; reimbursement 100%; use with E/M codes only.
26	Professional component; reimbursement 30%.
59	Distinct procedural service; use only if no more descriptive modifier available; CMS has X-subset modifiers XE/XP/XU/XS.
58	Staged or related procedure during postoperative period; reimbursement example 69%.
78	Unplanned return to OR during postoperative period; medical records may be required; reimbursement example 69%.
79	Unrelated procedure during postoperative period; reimbursement example 100%.
54	Surgical care only; indicates intra-operative portion only; reimbursement example 69%.

1–10 of 20

1/2

Required coding systems for claim submissionmixed

CPT	Current Procedural Terminology codes per AMA
ICD-10-CM	Diagnosis coding per International Classification of Diseases, 10th revision, Clinical Modification
HCPCS Level II	Healthcare Common Procedure Coding System Level II for supplies, services, etc.

Use of modifier 59 or X-subset

When to use modifier 59Use modifier 59 to identify procedures/services (other than E/M) that are not normally reported together only if no more descriptive modifier is available.

Prefer X‑subsets when appropriateWhen more specific circumstance applies, use CMS X‑modifiers (XE, XP, XU, XS) instead of modifier 59.

X‑modifier definitionsXE=Separate encounter; XP=Separate practitioner; XU=Unusual non‑overlapping service; XS=Separate structure.

timely filing

Timely filing requirementProviders must submit complete claims for payment within contractually determined timely guidelines.

Claim content standards

Provider responsibilities and documentation

Prior Authorization

Verify eligibility, coverage, and prior authorization

It is the provider's responsibility to verify member eligibility, coverage, and any required prior authorization before rendering services. Refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies, or contact Provider Services at 1-800-963-1001 with questions.

Documentation Required

Provide medical records upon request

Be prepared to provide medical records upon request to substantiate billed services and the medical necessity of those services; Neighborhood may request documentation for any billed service.

Documentation Required

Documentation standards and requirements

Key terms and member responsibility

Modifier (CPT/HCPCS)

DefinitionModifiers that affect claims processing and/or reimbursement are those accepted and described in this policy; non‑covered modifiers are addressed in Neighborhood's Non‑Covered Payment Policy.

ScopeApplies to standard CPT and HCPCS modifiers submitted in accordance with the appropriate procedure code(s).

ImpactAbsence of an appropriate modifier or use of an inappropriate modifier may result in claim denial or altered reimbursement.

Modifier 22

DefinitionModifier 22 — indicates an unusual procedural service when the procedure is substantially greater than typical and requires documentation of the additional work (intensity, time, technical difficulty, severity, physical/mental effort).

Documentation required

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse of CPT and HCPCS Modifiers Affecting Claims Processing and Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage, and authorization criteria and be prepared to provide medical records upon request to substantiate billed services.

SourceLink

On This Page

ALL of the following

Modifier 80: physician assistant surgeon who fully assists in the surgery.
Modifier 81: minimal assistance for a limited portion of the surgery.
Modifier 82: used at teaching hospitals when a qualified resident is not available or the teaching facility does not have the related teaching program.
Modifier AS: assistant at surgery is a non-physician provider (PA, NP, or clinical nurse specialist) and should not be billed by a physician.

Filing must meet standards defined by AMA CPT, ICD‑10‑CM, and HCPCS Level II codebooks.

Subject to contract termsTimely filing timelines are determined by applicable provider contracts and may vary by line of business.

Neighborhood reserves the right to request medical records for any billed service; documentation must support the services billed and their medical necessity and must follow CMS documentation standards.

Documentation must support the service(s) billed and the medical necessity.
Neighborhood follows CMS standards for proper documentation requirements.

Billing Rule

Timely claim submission and required coding systems

Submit complete claims within contractually determined timely filing guidelines and use the required coding systems: AMA CPT, ICD-10-CM, and HCPCS Level II.

Claims must meet standards defined by the AMA CPT codebook.
Use ICD-10-CM for diagnosis coding and HCPCS Level II for supplies/services.

Provider must document reason for additional work in the medical record to bill for additional reimbursement.

Reimbursement noteWhen approved, modifier 22 may impact reimbursement above standard rates (see modifier reimbursement guidance).

Modifier 24

DefinitionModifier 24 — indicates a post‑surgical E/M visit that is unrelated to the surgery and occurred outside the global surgical package.

Inclusion rulePost‑surgical visits billed by the physician who performed the surgery are considered inclusive in the surgical procedure and are not separately reimbursable unless unrelated to the surgery.

Billing guidanceAppend modifier 24 to the E/M code to indicate the visit is outside the global period and unrelated to the surgery.

Modifier 25

DefinitionModifier 25 — indicates a significant, separately identifiable Evaluation and Management (E/M) service performed by the same physician on the same day as a procedure or other service.

Use restrictionModifier 25 should be used with E/M codes only and not appended to the surgical procedure code(s).

DocumentationDocumentation must support that the E/M service was significant and separate from the procedure or other service performed the same day.

Modifier 59 / X-modifiers

DefinitionModifier 59 and X‑modifiers identify distinct procedural services that are not normally reported together (modifier 59 for distinct procedural services; X‑modifiers are more specific subsets).

When to use 59 vs XOnly use modifier 59 if no more descriptive X‑subset modifier is available; prefer XE/XP/XU/XS when they accurately describe the circumstance.

PurposeUsed to indicate procedures/services that are distinct or independent from other non‑E/M services performed on the same day when NCCI PTP edits would otherwise bundle them.

Disclaimer

Policy natureThis payment policy is informational only and is not a guarantee of reimbursement.

Payments subject toClaim payments are subject to benefit coverage, member eligibility, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and state/federal regulations.

Audit and changesNeighborhood reserves the right to update the payment policy at any time and all services billed are subject to audit.

Member Responsibility

Member cost sharingCommercial plan members may have coinsurance, copays, and deductibles and are responsible for out‑of‑pocket expenses based on plan selection.

Verify benefitsProviders and members should review cost‑sharing obligations or contact Member Services to finalize member charges prior to services.

Subject to eligibilityMember financial responsibility is subject to member eligibility, benefit coverage, and applicable contract terms.