Empire BlueCross BlueShield Professional Reimbursement Policy

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Subject: Modifier Rules

NY Policy: 0017

Effective: 02/01/2014 – 06/30/2014

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and policy criteria listed below.

DESCRIPTION

A modifier is made up of a two character alpha/numeric indicator that is appended to a Current Procedural Terminology (CPT®)′ or Healthcare Common Procedure Coding System (HCPCS Level II) code. It is used as a means of reporting a specific circumstance that further defines or alters the code; but it does not change the definition of the procedure performed or item procured.

POLICY

The Health Plan accepts for claims processing, but not always to determine compensation, all HIPAA compliant CPT and HCPCS modifiers. The Health Plan treats some modifiers as “informational only”; some modifiers are important to the adjudication of the claim; and some modifiers may affect the percentage of the allowed amount. Providers must follow proper coding guidelines as set by CPT or The Centers for Medicare & Medicaid Services (CMS) when reporting modifiers.

The Health Plan also uses ClaimsXten®″ for modifier to procedure code validation. ClaimsXten identifies if a modifier is inappropriately used with a procedure code. When an invalid modifier to procedure code combination is detected, the line item will be denied, with a request that the correct code and modifier combination be resubmitted. The Health Plan validates that the following modifiers are appropriately used with procedure codes: 22, 23, 24, 25, 26, 27, 50, 52, 53, 54, 55, 56, 57, 59, 62, 63, 73, 74, 76, 77, 78, 79, 80, 81, 82, 91, AA, AD, AS, E1-E4, F1-F9, FA, LC, LD, LM, LT, MS, P3, P4, P5, QK, QX, QY, QZ, RA, RB, RC, RI, RR, RT, T1-T9, TA, TC and UE.

In addition to modifier to procedure code validation, the following modifiers are used in the adjudication of a claim and may impact reimbursement.

Modifier Description Percent of

allowed amount

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

22 Increased Procedural Services 120% (if

approved) See Comments

• Procedure codes reported

with modifier 22 without operative notes/office notes will be reimbursed based on the allowed amount for the procedure code, without review for additional reimbursement.

• Procedure codes reported

with modifier 22 with operative notes/office notes will be reviewed to

determine if additional reimbursement is warranted.

24 Unrelated Evaluation and

Management Service by the Same Physician During a Post Operative Period*

* See also the Health Plan’s Global Surgery Reimbursement Policy.

No impact on percentage

When appended to an E/M procedure code, modifier 24 may override a surgical aftercare edit and the reported E/M code may be eligible for reimbursement

.

25 Significant, Separately

Identifiable * Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service*

*For more information, refer to the Health Plan’s Global Surgery and Evaluation and Management Services and Related Modifiers -25 & -57 Reimbursement Policies.

See Comments When appended to an E/M procedure code, modifier 25 may override the following edits and the reported E/M code may be eligible for reimbursement for:

• Same Day medical visit with a procedure

• Problem focused E/M

reported with preventive E/M

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

26 Professional Component See Comments Reimbursement is based on the

professional component of a procedure that has both a technical and professional component.

50 Bilateral Procedures*

*For more information, refer to the Health Plan’s Multiple and Bilateral Surgery Processing and Multiple Diagnostic Imaging Reimbursement Policies.

150% • Bilateral surgical services

are subject to the multiple surgery reimbursement rules. The surgical CPT code is required to be reported on one line with modifier 50 appended.

• Reimbursement is made at

the rate of 100% for the first side and 50% for the second side (100 +50 =150%)

• Diagnostic services,

including radiology, are not subject to multiple surgery reimbursement rules. Therefore, bilateral

procedures for this type of service are to be reported on two lines with the LT and RT site-specific modifiers. .

52 Reduced Services 50% Procedure codes reported with

modifier 52 are processed and reimbursed at 50% of the allowed amount.

53 Discontinued Procedure 50% Procedure codes reported with

modifier 53 are processed and reimbursed at 50% of the allowed amount.

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Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

54 Surgical Care Only*

* See also the Health Plan’s Global Surgery Reimbursement Policy.

70% • Surgical procedures reported

with modifier 54 are reimbursed at 70% of the allowed amount.

• Reimbursement is made for

the surgical procedure only.

• This lower % rate carves out the preop and post op care which is usually included in the global surgical

reimbursement for a surgical procedure.

• This modifier is reported with the surgical code when one provider performs the surgical procedure and another provides the preoperative and/or postoperative care.

55 Post Operative Management

Only*

* See also the Health Plan’s Global Surgery Reimbursement Policy.

20% • Surgical procedures reported

with modifier 55 are reimbursed at 20% of the allowed amount.

• This lower % rate carves out the preoperative visit and the surgery, which are usually included in the global

reimbursement for a surgical procedure.

• This modifier is reported with the surgical code when one provider performed the postoperative care and another performed the surgical procedure.

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Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

56 Preoperative Management

Only*

* See also the Health Plan’s Global Surgery Reimbursement Policy.

10% • Surgical procedures reported

with modifier 56 are reimbursed at 10% of the allowed amount.

• This lower % rate carves out the surgery and

postoperative care, which are usually included in the global reimbursement for a surgical procedure.

• This modifier is reported with the surgical code when one provider performed the preoperative care and another performed the surgery.

57 Decision For Surgery*

* See also the Health Plan’s Global Surgery and Evaluation and Management Services and Related Modifiers -25 & -57 Reimbursement Policies.

No impact on percentage

When appended to an E/M procedure code, modifier 57 will override the one-day pre-op and Same Day Procedure/ Medical visit edit; and the reported E/M code will be eligible for reimbursement.

59 Distinct Procedural Service*

* See also the Health Plan’s Bundled Services and Supplies, Frequency Editing, and

Modifier 59 Reimbursement Policies.

No impact on percentage

• Modifier 59 will, in many cases, affect the adjudication of the reported code by overriding incidental, mutually exclusive, and rebundle edits, allowing the reported procedure code to be eligible for separate reimbursement.

• This modifier will not:

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Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

code listed as “always bundled” in the Bundled Services and Supplies Reimbursement Policy

o override an edit for a code listed in the

“Exceptions to Modifier 59 Override” section of the Modifier 59

Reimbursement Policy

o override a duplicate procedure edit

o override frequency edit limits

62 Two Surgeons (Co-Surgery)*

* For more information, refer to the Health Plan’s

Co-Surgeon/Team Surgeon Services Reimbursement Policy.

63% per surgeon • When two surgeons act as

co-surgeons, each surgeon will receive 63% of the allowed amount for an individual code.

• This lower reimbursement

rate reflects the shared responsibility for global surgical services.

63 Procedure performed on infants 120% Except for those codes

described in Appendix F of the CPT Manual, procedures reported with modifier 63 are eligible for additional

reimbursement.

66 Surgical Team*

* For more information, refer to the Health Plan’s

Co-Surgeon/Team Surgeon Services Reimbursement Policy.

No impact on percentage

This modifier has no effect on the allowed amount of the reported surgical code, but is important to establish team surgery status in the

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

76 Repeat Procedure or Service by

Same Physician or Other Qualified Health Care Professional

No impact on percentage

•When appended to a

procedure code, modifier 76 indicates that the repeated procedure/service is not a duplicate.

•A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code.

77 Repeat Procedure or Service by

Another Physician or Other Qualified Health Care Professional

No impact on percentage

•When appended to a

procedure code, modifier 77 indicates that the repeated procedure/service is not a duplicate.

•A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code.

78 Unplanned Return to the

Operating / Procedure Room by the Same Physician or Other Qualified Health Care

Professional Following Initial Procedure for a Related Procedure During the Postoperative Period* * See also the Health Plan’s Global Surgery Reimbursement Policy.

70% • Surgical procedures reported

with this modifier are reimbursed at 70% of the allowed amount.

• This lower % rate carves out the pre-op and post op- care which is usually included in the global surgical

reimbursement for a surgical procedure.

79 Unrelated Procedure or Service

by the Same Physician During the Post Operative Period

No impact on percentage

When appended to a procedure or service, modifier 79 will override global surgical editing and the reported procedure code will be eligible for

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Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

reimbursement.

80 Assistant Surgeon*

*For more information, refer to the Health Plan’s Assistant Surgeon Services

Reimbursement Policy.

16% • Surgical procedures reported

with modifier 80 are

reimbursed at 16% of the total allowed amount for the

reported code.

•Modifier 80 should not be used to report assistant surgeon services rendered by non-physician providers.

81 Minimum Assistant Surgeon*

*For more information, refer to the Health Plan’s Assistant Surgeon Services

Reimbursement Policy.

16% • Surgical procedures reported

with modifier 81 are

reimbursed at 16% of the total allowed amount for the

reported code.

•Modifier 81 should not be used to report minimum assistant surgeon services rendered by non-physician providers.

82 Assistant Surgeon (When

Qualified Resident Surgeon Not Available)*

*For more information, refer to the Health Plan’s Assistant Surgeon Services

Reimbursement Policy.

16% • Surgical procedures reported

with modifier 82 are

reimbursed at 16% of the total allowed amount for the

reported code.

•Modifier 82 should not be used to report assistant surgeon services rendered by non-physician providers.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

91 Repeat Clinical Diagnostic

Laboratory Test*

*For more information, refer to the Health Plan’s Frequency Editing Reimbursement Policy

No impact on percentage

When modifier 91 is appended to a reported laboratory procedure code, our claims editing system will override a frequency edit and allow separate reimbursement for the repeat clinical diagnostic laboratory test except as described in our Frequency Editing Reimbursement Policy related to drug screen testing

99 Multiple Modifiers See Comments Identifies when multiple

modifiers would be applicable.

AD Medical Supervision by a

Physician: More than four concurrent anesthesia procedures

See Comments Anesthesia procedures reported

with modifier AD will be reimbursed at 50% of the anesthesia allowed amount.

AS Physician Assistant, Registered

Nurse First Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery*

*For more information, refer to the Health Plan’s Assistant Surgeon Services

Reimbursement Policy.

14% of MD fee schedule

•Surgical procedures reported with modifier AS are

reimbursed 14% of MD fee schedule if there is no

separate fee schedule for non-physician providers.

•Modifier AS is to be used for reporting assistant-at-surgery services by non-physician providers.

CC Procedure Code Change No impact on

percentage

See Health Plan’s instructions for information regarding corrected claims submission.

E1-E4 Eyelids No impact on

percentage

These site-specific modifiers are recognized by ClaimsXten and may override applicable edits.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

F1-F9, FA Hand, Digit No impact on

percentage

These site-specific modifiers are recognized by ClaimsXten and may override applicable edits.

GQ Via asynchronous

telecommunications system* *See the Health Plan’s Telemedicine and Telehealth Reimbursement Policy

See Comments Services billed with modifier

GQ will be processed according to the Health Plan’s

reimbursement policy for Telemedicine and Telehealth.

GT Via Interactive Audio and

Video Telecommunication Systems*

*See the Health Plan’s Telemedicine and Telehealth Reimbursement Policy

See Comments Services billed with modifier

GT will be processed according to the Health Plan’s

reimbursement policy for Telemedicine and Telehealth.

KC Replacement of special power

wheelchair interface*

*See the Health Plan’s Durable Medical Equipment Policy

See Comments Modifier KC is required for

replacement of special power wheelchair interface to be eligible for reimbursement.

LC Left Circumflex Coronary

Artery

No impact on percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

LD Left Anterior Descending

Coronary Artery

No impact on percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

LL Lease/Rental (Used when DME

equipment rental is to be applied against the purchase price)

See Comments Monthly rental is equivalent to

1/10th of the allowed amount for a DME purchase.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

LM Left Main Coronary Artery No impact on

percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

LT Left Side No impact on

percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

MS Six month maintenance and

servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty*

*See the Health Plan’s Durable Medical Equipment (DME) Reimbursement Policy

See Comments • A DME item that is eligible

for maintenance reimbursement will be reimbursed no more than two times per year at a frequency of at least 179 days apart.

• A DME item that is not

eligible for maintenance reimbursement will be denied.

NR New when rented (use the NR

modifier when DME which was new at the time of rental is subsequently purchased)* *See the Health Plan’s Durable Medical Equipment Policy

See Comments Modifier NR is required for

item to be eligible for reimbursement of purchase.

NU New equipment—purchase*

*See the Health Plan’s Durable Medical Equipment Policy

See Comments Modifier NU is required for

item to be eligible for reimbursement of purchase.

P3, P4, P5 Anesthesia Physical Status

Modifiers*

*See the Health Plan’s Anesthesia Reimbursement Policy

See Comments Anesthesia codes reported with

the modifiers P3, P4, or P5 are eligible for additional unit reimbursement as follows: P3= 1 unit

P4= 2 units P5 = 3 units

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

PA Surgery or other invasive

procedure on wrong body part

See Comments Procedures reported with this

modifier will be denied.

PB Surgery or other invasive

procedure on wrong patient

See Comments Procedures reported with this

modifier will be denied.

PC Wrong surgery or other invasive

procedure on patient

See Comments Procedures reported with this

modifier will be denied.

QK Medical Direction of two, three,

or four concurrent anesthesia procedures involving qualified individuals*

*See the Health Plan’s Anesthesia Reimbursement Policy

50% • The 50% reimbursement

rate for medical direction carves out the

reimbursement for the qualified professional who actually administered the anesthesia service.

• Total reimbursement for an

anesthesia service is never more than the allowed amount.

QX CRNA Service with medical

direction by a physician* *See the Health Plan’s Anesthesia Reimbursement Policy

50% • The 50% reimbursement

rate for medical direction carves out the

reimbursement for the qualified professional who actually administered the anesthesia service.

• Total reimbursement for an

anesthesia service is never more than the allowed amount.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

QY Medical direction of one CRNA

by an anesthesiologist* *See the Health Plan’s Anesthesia Reimbursement Policy

50% • The 50% reimbursement

rate for medical direction carves out the

reimbursement for the qualified professional who actually administered the anesthesia service.

• Total reimbursement for an

anesthesia service is never more than the allowed amount.

RA Replacement of a DME,

Orthotic, or Prosthetic Item* *See the Health Plan’s Durable Medical Equipment Policy

See Comments Replacement of Health

Plan-defined “frequently serviced”

DME items will be denied. Health Plan requires frequently

serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee.

RB Replacement of a Part of a

DME, Orthotic, or Prosthetic Item Furnished as Part of a Repair*

*See the Health Plan’s Durable Medical Equipment Policy

See Comments Replacement of parts of Health

Plan-defined “frequently serviced” DME items will be denied. Health Plan requires frequently serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee.

RC Right Coronary Artery No impact on

percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

RI Ramus Intermedius Coronary

Artery

No impact on percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

RR Rental

* For more information, refer to the Health Plan’s Durable Medical Equipment Reimbursement Policy.

See Comments Monthly rental is equivalent to

1/10th of the maximum allowance for a purchase.

RT Right Side No impact on

percentage

This site-specific modifier is recognized by ClaimsXten and may override applicable edits.

SL State Supplied Vaccine See Comments A vaccine supplied by a state

government agency at no cost to the provider is not eligible for reimbursement by the Health Plan.

SU Procedure performed in

physician’s office (to denote use of facility and equipment).

See Comments Procedures reported with

modifier SU will not be eligible for separate reimbursement if a provider is not contracted for the modifier’s use. Use of an office facility and equipment are included in the practice expense of the Relative Value Unit (RVU) for a rendered service or procedure.

T1-T9, TA Left/Right Foot, Digit No impact on

percentage

These site-specific modifiers are recognized by ClaimsXten and may override applicable edits.

TC Technical Component See Comments Reimbursement is based on the

technical component of a procedure that has both a technical and professional component.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Percent of

allowed amount

Comments

UE Used durable medical

equipment—purchase*

*See the Health Plan’s Durable Medical Equipment Policy

See Comments Modifier UE is required for item

to be eligible for reimbursement of purchase.

The following table lists some (but not all) commonly reported modifiers that the Health Plan

considers “Informational only”. These modifiers have no effect on the allowed amount of the reported code.

Modifier Description Comments

23 Unusual Anesthesia*

* For more information, refer to the Health Plan’s Anesthesia Reimbursement Policy.

• Informational only with no additional compensation. This modifier has no effect on the reimbursement of the reported anesthesia code.

• The provider should append the appropriate physical status modifier P1-P6 to indicate a specific physical condition.

32 Mandated Services Informational only. This modifier has no

effect on the allowed amount for a covered procedure code.

33 Preventive Service Preventive services reported with this modifier

may be covered at the member’s applicable preventive health level of benefits.

47 Anesthesia by Surgeon Informational only with no additional

compensation. This modifier has no effect on the allowed amount for the reported procedure code.

51 Multiple Procedures • Informational only. This modifier has no

effect on the allowed amount for the reported procedure code.

• The Health Plan determines the ranking for applying multiple surgery reimbursement rules through its claim processing system

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Comments

not through the use of this modifier.

58 Staged or related procedure or

service by the same physician during the postoperative period

Informational only.

90 Reference (Outside) Laboratory Informational only.

92 Alternative Laboratory Platform

Testing

Informational only.

AA Anesthesia Services Performed

Personally by Anesthesiologist

Informational only. This modifier has no effect on the reimbursement for the reported

anesthesia code.

AI Principal physician of record Informational only

G8 Monitored Anesthesia Care

(MAC)

Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code.

G9 Monitored Anesthesia Care

(MAC)

Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code.

GC This service has been performed

in part by a resident under the direction of a teaching physician

Informational only

GE This service has been performed

by a resident without the

presence of a teaching physician under the primary care exception

Informational only

GR This service was performed in

whole or in part by a resident in a Department of Veterans Affairs Medical Center or clinic, supervised in accordance with VA policy.

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Empire BlueCross BlueShield

Professional Reimbursement Policy

Modifier Description Comments

P1, P2, P6 Anesthesia Physical Status Modifiers*

*See the Health Plan’s Anesthesia Reimbursement Policy

• Informational only.

• Anesthesia codes reported with modifier P1, P2, or P6 are not eligible for additional unit reimbursement.

PT Colorectal cancer screening test

converted to a diagnostic test

Colorectal cancer screening procedures may be covered at the member’s applicable preventive health level of benefits.

QL Patient Pronounced Dead After

Ambulance Called

Informational only. This modifier has no effect on the reimbursement of the reported service.

QS Monitored Anesthesia Care

(MAC)

Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code.

QZ CRNA Service without medical

direction by a physician* *See the Health Plan’s Anesthesia Reimbursement Policy

Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code.

1 CPT © is a registered trademark of the American Medical Association 4 ClaimsXten is a registered trademark of McKesson Information Solutions LLC

Use of Reimbursement Policy:

State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. © 2014 Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield.

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