CurrentPremera BluecrossPolicy cmi_051766

Modifier 63 - Procedure performed on infants less than 4 kg

Defines when Premera recognizes Modifier 63 on professional surgical claims for procedures performed on neonates/infants under 4 kg and who this applies to across Premera and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyModifier 63 - Procedure performed on infants less than 4 kg

Policy CodePolicy cmi_051766

Change TypeRevised policy with documentation requirementclarified purposeadded appendix references

Effective Date

Next Review Date

Key ActionAppend Modifier 63 to eligible surgical procedure codes for neonates/infants under 4 kg and document the significantly greater effort and reasons in the medical record.

SourceLink

POLICY UPDATE CHANGES

Revised Policy to reference increased work/complexity and added documentation requirement that records identify significantly greater effort and reasons.

Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P claim forms.

Called out code exceptions in the Medicine/Cardiovascular section that can also be billed with Modifier 63.

multiple linesPlan entities covered

20100-69990Allowed CPT code range

2026-04-02Archive date

through 2026-03-12Review history

Modifier 63 Coverage Criteria

Modifier 63 coverage criteria

Recognition criteria for Modifier 63

Applies to neonates/infants weighing less than 4 kilograms at time of service (patient weight < 4 kg).

Applies to neonates/infants weighing less than 4 kilograms at time of service.

Modifier 63 may be appended only to specific invasive surgical procedures: generally CPT codes in the range 20100-69990 OR the identified cardiovascular Medicine codes listed in CPT Appendix A under Modifier 63.

Modifier 63 limited to surgical procedures and specified cardiovascular medicine codes; not appropriate for E&M, Anesthesiology, Radiology, Laboratory/Pathology, or general Medicine codes.

Do not append Modifier 63 to codes whose descriptions already include the term 'neonate' or 'infant' (these codes already reflect additional work).

Documentation: medical records must identify the significantly greater effort required and the reasons for the additional work.

Policy Summary

PayerPremera Bluecross

PolicyModifier 63 - Procedure performed on infants less than 4 kg

Policy CodePolicy cmi_051766

Change TypeRevised policy with documentation requirementclarified purposeadded appendix references

Effective Date

Next Review Date

Key ActionAppend Modifier 63 to eligible surgical procedure codes for neonates/infants under 4 kg and document the significantly greater effort and reasons in the medical record.

SourceLink

On This Page

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Billing Expectations and Documentation

Billing Rule

Billing expectation: Use Modifier 63 for qualifying infant surgical procedures (<4 kg)

Append Modifier 63 to eligible surgical procedure codes (generally CPT 20100-69990 and the specified cardiovascular Medicine codes in CPT Appendix A) when the procedure was performed on a neonate/infant weighing less than 4 kg and involved significantly greater complexity and provider work. Do not append Modifier 63 to E&M services or codes in the Anesthesiology, Radiology, Laboratory/Pathology, or Medicine sections except the identified cardiovascular codes. Do not bill Modifier 22 with Modifier 63 on the same code line. Documentation in the patient's medical record must identify the significantly greater effort required and the reasons for the additional work.

Applicable code range: CPT 20100-69990 plus specified cardiovascular Medicine codes listed in CPT Appendix A under Modifier 63.
Exclusions: codes already describing 'neonate' or 'infant' (see CPT Appendix F) should not be appended with Modifier 63.
Never append Modifier 63 to E&M, Anesthesiology, Radiology, Laboratory/Pathology, or general Medicine codes (except specified cardiovascular codes).
Modifier 22 is not appropriate and must never be billed together with Modifier 63 on the same code line.
Medical record documentation must state the significantly greater effort and reasons for additional work.

Key Definitions

Modifier 63 - short definition

DefinitionModifier 63 — Procedure performed on infants less than 4 kg: appended to indicate specific invasive surgical procedures performed on neonates/infants weighing less than 4 kilograms that involved a significant increase in complexity and provider work.

Eligible code rangeGenerally appended to procedures/services in CPT code range 20100-69990 and identified cardiovascular Medicine codes per CPT Appendix A (Modifier 63 entry).

Documentation requirementMedical records should identify the significantly greater effort required and the reasons for the additional work.

Modifier 22 — guidance

ApplicabilityModifier 22 (Increased procedural services) is not appropriate for use with services rendered to an infant or neonate weighing less than 4 kg at the time of service.

Billing restrictionModifier 63 and Modifier 22 should never be billed together on the same code line.

RationaleModifier 63 is the designated modifier to indicate significantly greater complexity/work for procedures on infants <4 kg; Modifier 22 should not be used in this context.

20100-69990	CPT surgical procedure code range generally eligible for Modifier 63
Medicine - cardiovascular codes (per CPT Appendix A/Modifiers)	Specified cardiovascular medicine codes allowed with Modifier 63

OpenPayer

Modifier 63 - Procedure performed on infants less than 4 kg

Modifier 63 Coverage Criteria

Eligible and Ineligible Codes; Weight Threshold

Billing Expectations and Documentation

Key Definitions