Blue Cross and Claim Edits

What to do when BCBSIL denies a claim for modifiers -25 and -59

NEARLY A year ago, Blue Cross and Blue Shield of Illinois (BCBSIL) announced an “enhancement” to its code-auditing software so the insurer could assess appropriate use of modifiers submitted on claims. The change, implemented in November 2017, focused on modifiers -25 and -59. Now, as a result of this new claims processing logic, BCBSIL automatically edits any claim submitted with modifiers -25 and -59 for review.

BCBSIL will deny a claim if the modifier is used incorrectly or can’t be validated. While BCBSIL may reimburse for the original procedure, payment for the modifier claim won’t be released until supporting information is received.

In such situations, BCBSIL says not to submit an appeal. Instead, providers should validate the use of the modifier on the claim by submitting medical records for further review/reconsideration. Providers may use the online “Claim Inquiry Resolution” tool, accessible via the Availity web portal and also use the appropriate claim review form in the “Forms” section.

Each review is member-specific and relevant information is compiled to determine if modifiers can be validated. The CPT coding guidelines state that a modifier provides the means to report or indicate a service or procedure that was performed was affected by some specific circumstance but not necessarily changed per the definition of the code.

As described by CPT: Modifier 25 is used to denote a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.” Modifier 25 should be submitted only on an E/M code. Providers should consult the CPT Manual for details on code combinations in addition to CMS NCCI edits.

According to CPT: “Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together that may be appropriate under certain circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual.” Providers should follow CPT guidelines as outlined in the current year’s CPT Manual in addition to CMS NCCI edits.