CurrentPremera BluecrossPolicy N/A

Modifier 63 — Procedure performed on infants less than 4 kg

Defines when Premera recognizes Modifier 63 on professional surgical claims for neonates and infants under 4 kg and applicability across Premera/LifeWise lines of business.

Policy Summary

PayerPremera Bluecross

PolicyModifier 63 — Procedure performed on infants less than 4 kg

Policy CodePolicy N/A

Change TypeAnnual review — no changes

Effective DateN/A

Next Review Date03/07/25

Key ActionAppend Modifier 63 to eligible procedure codes when performed on neonates/infants under 4 kg and do not append with Modifier 22.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20100-69990CPT range eligible

<4 kgWeight threshold

Appendix FExempt codes

Payment IntegrityPolicy owner

Across Premera/LifeWiseApplicability

When Modifier 63 Is Recognized

Modifier 63 coverage criteria

Covered when ALL of the following are met:

ALL of the following

Patient must be a neonate/infant weighing less than 4 kg at time of service
Modifier 63 may be appended only to procedures/services in CPT range 20100-69990 and the identified cardiovascular Medicine codes per the CPT Appendix A entry for Modifier 63; codes whose description already include 'neonate' or 'infant' should not be appended with Modifier 63 (reimbursement for those codes already reflects additional work)
Modifier 63 should not be appended to Evaluation and Management (E/M) services or codes in the Anesthesiology, Radiology, Laboratory/Pathology or Medicine sections of the CPT Codebook except for the identified cardiovascular Medicine codes noted in Appendix A
Modifier 63 and Modifier 22 must not be billed together on the same code line

Policy Summary

PayerPremera Bluecross

PolicyModifier 63 — Procedure performed on infants less than 4 kg

Policy CodePolicy N/A

Change TypeAnnual review — no changes

Effective DateN/A

Next Review Date03/07/25

Key ActionAppend Modifier 63 to eligible procedure codes when performed on neonates/infants under 4 kg and do not append with Modifier 22.

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.

Eligible and Exempt Codes; Key Thresholds

Modifier 63-eligible and exempt codesCPT

20100-69990	General CPT surgical procedures range eligible for Modifier 63 unless otherwise designated
See CPT Appendix A and Appendix F	Cardiovascular Medicine section codes allowed and codes exempt from Modifier 63 per CPT appendices

inv-03: Patient weight threshold

Weight thresholdPatient must weigh less than 4 kg at time of service to qualify for Modifier 63

Documentation requirementMedical record must document the significantly greater effort required and reasons for additional work

Applies to neonates/infantsModifier 63 specifically applies to neonates and infants weighing less than 4 kg

Billing Guidance and Provider Responsibilities

Billing Rule

Modifier 63 billing guidance

Append Modifier 63 to eligible surgical procedure codes when the service was performed on a neonate or infant weighing less than 4 kg to indicate significantly increased complexity and provider work. Do not append Modifier 63 to E/M services or codes in the Anesthesiology, Radiology, Laboratory/Pathology sections (except the specified cardiovascular Medicine codes), and do not append it to codes whose descriptions already include “neonate” or “infant.” Modifier 63 and Modifier 22 must not be billed together on the same code line.

Eligible CPT range (unless otherwise designated): 20100-69990; select cardiovascular Medicine codes per CPT Appendix A (Modifier 63 entry).
Refer to CPT Appendix F for codes exempt from Modifier 63.
Documentation must identify the significantly greater effort required and reasons for additional work.

Definitions of Modifiers and Related Terms

inv-05: Procedure performed on infants less than 4 kg to indicate significantly increased complexity and work

Definition (Modifier 63)Procedure performed on infants less than 4 kg to indicate significantly increased complexity and work

Eligible proceduresApplies to specific invasive surgical procedures performed on neonates/infants under 4 kg

Exempt codesCodes whose descriptions already include 'neonate' or 'infant' should not be appended with Modifier 63

inv-06: Increased procedural services (not appropriate for use with Modifier 63 on neonatal/infant services)

Modifier 22 relationshipModifier 22 (Increased procedural services) is not appropriate for use with services rendered to an infant or neonate weighing less than 4 kg; Modifier 63 and Modifier 22 must not be billed together on the same code line

Service type exclusionsModifier 63 should not be appended to Evaluation and Management (E/M) services or codes in Anesthesiology, Radiology, Laboratory/Pathology sections (except specified cardiovascular Medicine codes)

Documentation impactWhen Modifier 22 is not appropriate, the documentation requirement for Modifier 63 remains: record the significantly greater effort and reasons for additional work