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Use of Modifiers


Provider Administrative Policy

Section
Provider Information
Policy Date
April 2007
Status/Date
Revised/June 2013

Disclaimer

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.

Policy

Use of Modifiers

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.

Advanced Beneficiary Notification (ABN) Modifiers
Physicians, practitioners, and suppliers must use:

  • The GA modifier when reporting they obtained an ABN required by payer policy
  • The GY modifier to indicate that the item or service is statutorily non-covered or is not a Medicare-covered benefit
  • The GX modifier to indicate issuance of a voluntary ABN for a service. Providers can bill the GX modifier on the same claim line as a GY modifier
  • The GZ modifier to indicate when they expect denial of an item or service as not reasonable and necessary and they do not have a member signed ABN.

Effective process date 05/16/2011, claims submitted with GA,GX or GY modifiers indicating a valid ABN has been signed, will process as member liability. 

Please remember the providers may not use the ABN to circumvent Blue Cross of Idaho prior authorization requirements.

(ABN Form Example). 

Blue Cross of Idaho recommends providers give members a copy of the signed ABN for their records.

Ambulance Modifiers
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:

Modifier

 Meaning

 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)

 H

 Hospital

 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)

 R

 Residence

 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.

Hospice Modifiers
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 line. 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.

Therapy Modifiers
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) modifer in the primary position for post cataract appropriate hardware claims. Append this modifier to the hardware codes only.

Submit claims for optical services without the SC modifier when a member's vision benefit applies.


Policy History

Date Action Reason
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

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