Use of Modifiers
Provider Administrative Policy
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts
Below are the most frequently questioned modifiers; however this list is not all-inclusive. For further information, please refer to coding and the Centers for Medicare and Medicaid Services (CMS) sources or contact your Blue Cross of Idaho provider relations representative.
New as of January 1, 2015: CMS established four new HCPCS modifiers to define subsets on modifier 59.
Subset modifiers are designed to reduce improper use of modifier 59 and improve claims processing for providers.
The new modifiers are:
XE - Separate Encounter; A service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
XS - Separate Structure; A service that is distinct because it was performed on a separate organ/structure.
XP - Separate Practitioner; A service that is distinct because it was performed by a different practitioner.
XU - Unusual Non-Overlapping Service; The use of a service that is distinct because it does not overlap the usual components on the main service.
We require ambulance providers to submit claims showing an origin and destination modifier. We will deny claims without an origin and destination modifier and the origin zip code for corrected billing.
Valid origin and destination modifiers include the following:
|D||Diagnostic or therapeutic site other than P or H|
|E||Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility)|
|G||Hospital-based dialysis facility (hospital or hospital related)|
|I||Site of transfer (airport or helicopter pad between types of ambulance)|
|J||Non-hospital-based dialysis facility|
|N||Skilled nursing facility (SNF)|
|P||Physician's office (including HMO non-hospital facility, clinic)|
|S||Scene of accident or acute event|
|X||Intermediate stop at physician's office en route to the hospital (includes HMO non-hospital facility, clinic) Note: Modifier X can only be used as a designation code in the second modifier position.|
Note: Use Modifier QL when someone calls for an ambulance but the member dies before it arrives at the scene. Payment for BLS services with this modifier is acceptable, except for mileage or a rural adjustment.
Chiropractic Service Modifiers
Submit manipulation codes using the AT modifier to indicate the services are active treatment.
Medicare revisions made in October 2010 state medical claims are the responsibility of Original Medicare when a Medicare Advantage member elects hospice at the time of service. If a provider bills a hospice claim to Blue Cross of Idaho Medicare Advantage, regardless if the services relate to the hospice diagnosis, we will deny the claim with a remark code indicating to bill Original Medicare. Blue Cross of Idaho will not forward these claims to Original Medicare.
The one exception is claims for supplemental services Blue Cross of Idaho Medicare Advantage provides for services not covered by Original Medicare, such as routine eyewear and examinations. Please continue to bill those services to Blue Cross of Idaho Medicare Advantage.
Multiple Surgery Modifiers
Ambulatory surgical centers with claims for multiple surgical procedures occurring on the same day must bill each surgical procedure on its own claim. Append the 51 modifier to all but the primary surgical procedure.
Returning to Operating Room Modifiers
Use CPT Modifier 78 for surgical procedures that require a return to the operating room for a related procedure during the post-operative period. For this type of service, Blue Cross of Idaho pays 70 percent of the maximum allowance or the billed charge, whichever is less.
For proper claim processing, include one of the therapy modifiers listed below for physical therapy, occupational therapy and/or speech therapy claims:
- GN - Services delivered under an outpatient speech-language pathology care plan.
- GO - Services delivered under an outpatient occupational therapy care plan.
- GP - Services delivered under an outpatient physical therapy care plan.
Therapists should use the appropriate physical therapy modifier for wound therapy claims.
Vision Care Modifiers
Use the SC (medically necessary service or supply) modifier in the primary position for post cataract appropriate hardware claims. Append this modifier when a member's vision benefit applies.
|December 2014||Revised||Added new modifiers for 2015|
|June 2013||Revised||Removed Global Period Billing section|
|June 2012||Revised||Removed instructions on claims prior to process date 05/16/11|
|December 2011||Revised||Removed language regarding Non ESRD Erythropoiesis Stimulating Agent (ESA) Modifiers|
|September 2011||Revised||Added pricing information for modifiers 54 & 55|
|November 2010||Revised||Assistant surgeon modifier language removed|
|August 2010||Revised||Modifier language added|
|January 2010||Revised||Assistant surgeon modifiers added|
|July 2009||Revised||Added 54 and 55 modifiers|
|March 2009||Revised||Added multiple surgery modifier section|
|November 2008||Revised||Language clarification|
|August 2008||Revised||Modifier language added|