Modifier Payment Policy Changes on the Horizon

Effective May 17, Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) will implement policy and procedural changes in regard to how services submitted with certain modifiers are reimbursed. The insurer notified participating physicians of the changes in a letter dated February 2010.

On or after May 17, Horizon BCBSNJ claim processing systems will recognize services submitted with certain modifiers as “nonstandard” (i.e., the full service was not performed or the service was performed in conjunction with another service or procedure).

Horizon BCBSNJ says it will reimburse:

  • Modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service at 50 percent the applicable Horizon BCBSNJ fee schedule amount (compared to the current reimbursement rate of 100 percent that is standard).
  • Modifier 52 Reduced services at 50 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 53 Discontinued procedure at 25 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 54 Surgical care only at 75 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 55 Postoperative management only at 15 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 56 Preoperative management only at 10 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 59 Distinct procedural service at 50 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia at 50 percent the applicable Horizon BCBSNJ fee schedule amount.
  • Modifier 76 Repeat procedure or service by same physician in an ASC at 50 percent the applicable Horizon BCBSNJ fee schedule amount.

The policy changes, according to Horizon BCBSNJ, are based on National Correct Coding Initiative (NCCI) guidelines and current industry policy.

You can view the various modifier policies on the Horizon BCBSNJ Physicians/Facilities website.

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11 Responses to “Modifier Payment Policy Changes on the Horizon”

  1. Lori Fiandra says:

    I have written a letter to Horizon regarding the implementation of this new policy. A 50% reduction in reimbursement in the evaluation and management of a patient is nothing short of a crime. All of the physicians in New Jersey need to rise up against this policy.

  2. Jennifer B. says:

    If New Jersey can do this, I wonder if other states will try as well?

  3. Margaret Nahmias says:

    Maybe that in addition the other procedure, don’t forget modifers 25 and is attached when you have separate procedure

  4. Susan L. says:

    The % of surgical aftercare care doesn’t seem right to me, especially for conditions that require more than one follow-up visit. How many claims are really reported this way to begin with? Industry standards seem to be that these modifiers are not used and that E/Ms are billed for routine surgical follow-up visits with a provider other than the surgeon. It is about time for that to change or has it already begun to?

    Interesting that modifier -25 is listed but -57 isn’t. They both have the same basic meaning. Could the reason be that there is a certain amount of preservice work to the minor procedures that warrant a lessor E/M because there really isn’t much of an assessment that is needed? An example is wart removal. To me, it would only be appropriate to bill an E/M if a procedure wasn’t done. It doesn’t take much to look at a wart to know how to treat it. It wouldn’t take much to look at a skin lesion and decide to biopsy or not. But what now happens to the visits that DO warrant full payment for the E/M? My guess is that there are more of those than not.

    I don’t understand how these changes are based on the NCCI guidelines. What’s changed with them?

  5. Shannon Sadilek says:

    The whole point of modifier 25 is to be paid for an evaluation and management service that is SIGNIFICANTLY separate and identifiable. We see many patients who after evaluating the patient, we schedule them for an angiogram. We offer to do this the same day for convenience to the patient. Now physicians will have to tell the patient to return the next day in order to be fully reimbursed for the evaluation service performed. This is no way related to a NCCI guideline.

  6. Susan L says:

    I’d bet that SIGNIFICANTLY is defined differently depending on who it affects.

    A provider would say that they did do an assessment of that wart or lesion and there would be a note with history, exam and decision making. Chief complaint-lesion on finger, HPI-lesion on rt pinky finger for 2 weeks, Exam-wart on rt finger, Medical decision making-discussed treatment options, patient would like cryo. That work is documented as a 99212 and with all the payment cuts providers seem to have to take, who wouldn’t want to get paid for this assessment, especially if it were a new patient?

    A patient would say “Jeeze, all you did was look at it. Why are you charging me for both of these things?”

    Paying only 50% for a modifier -25 as policy isn’t the right thing to do. Charging an office visit when only removing a wart isn’t the right thing to do, either. Neither is telling the patient to come back another day. These are all separate “solutions” that do not help the whole.

    Perhaps enough providers will respond to this and Horizon will change their modifier policy. THAT is what really needs to happen.

  7. Pawan Arya, MBA, CMPE, CPC, CPC-H says:

    The policy is unreasonable and high handedness on part of Horizon Blue Cross (which impacts theentire tri-state). Although everyone mentions mod 25 there is no mention of 50% payment for mod 59 which will have even worse impact on reimbursements.

    For example, for Oncology drug infusions hydration codes need a modified and subsequest hydration is paid at much lower rate than initial hour – think around $25. With mod 59, payment will be further cut to half. This will be real hard on Oncology Centers who do a number of infusions. Compound that to the mod 25 for E&M visit reduction.

  8. Michelle says:

    Our doctor has patients asking for osteopathic manipulation and it is billed with a modifier 25 because it is in addition to an office visit. Guess we’ll do them on separate days. What a pain!

  9. Gail Williams says:

    I feel that cutting the reimbursement on Modifier 25 is outrageous. The whole point in using this modifier is to get paid for the “significant separately Identifiable” evaluation and management service done by the same physician, on the same day as another service or procedure. Otherwise this would be bundled. Our doctors deserve to get paid for what they do. A 50% cut is not fair. Every year reimbusement get lower and lower. The cost to maintain a practice gets higher and higher. Give us a break!!!!!

  10. John Turner says:

    Perhaps it would be instructive to actually go to the Horizon policy site:

    https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_25.pdf

    The reference to the 25 modifier refers to 2 separate E&M services by the same physician on the same day. It states that an E&M + a non-E&M service will be paid at 100%. There may be confusion based on the above note that states…”Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service at 50 percent”

    The actual Horizon policy does not reflect that wording. I would advise checking with the actual policy before anyone jumps to the wrong conclusion. I am not sure where the above statement was found, but it does not accurately reflect the content of the Horizon policy #021B, effective May 17, 2010.

  11. Timothy Webb says:

    We’ve been notified in Kentucky the policy will begin January 1 (2112).

    Contrary to John Turner’s assumption, this policy was SPELLED OUT with specific procedure codes with which a separate E&M will only be payable at 50% regardless of ICD associated with it.

    This is it for us. Unless this is rescinded, we will no longer accept Blue Cross insurance !!

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