CatheB
Contributor
Does anyone know the modifier that Federal BCBS is wanting us to use on lumbar x-rays-72100? We do the technical and the reading of the x-rays so it's not TC or 26.
I have reached out to Federal BCBS and told them that we do both components (TC and 26), and was told that they require a modifier and that is why it keeps rejecting. I specifically what modifier would I use since we do the professional and technical components and was told that I would have to read their policy on it to find out. I have read and looked everywhere that I can think of and there isn't a modifier that would fit. Thank you for your advice.Since you’re performing both the technical component (taking the X-ray) and the professional component (reading/interpreting the X-ray) for CPT code 72100 (lumbar spine X-ray, 2-3 views), you’re providing the "global service." Typically, when billing a global service to most payers, including Medicare, no modifier is required because the CPT code 72100 without modifiers inherently includes both components.
However, Federal Blue Cross Blue Shield (BCBS) may have specific policies or edits that require a modifier in certain situations, even for global billing. Based on standard coding practices and the information available, here are some possibilities to consider:
No Modifier Needed: If you’re billing globally (both technical and professional components) and the service is performed in a non-facility setting (e.g., your own office with your own equipment), you should generally report 72100 without any modifier. This is the standard for global billing unless the payer specifies otherwise.
Modifier 59 (Distinct Procedural Service): If Federal BCBS is denying the claim due to a bundling edit (e.g., if the X-ray is performed alongside another procedure they consider related), they might expect modifier 59 to indicate that the lumbar X-ray is a distinct service. This would only apply if there’s another procedure on the same claim triggering the edit.
Payer-Specific Modifier: Some BCBS plans have unique requirements that deviate from standard CPT guidelines. For example, they might require a modifier to clarify billing circumstances, such as bilateral procedures or multiple imaging studies, though this is less likely for 72100 since it’s a straightforward 2-3 view lumbar X-ray.
Check for Policy Edits: Federal BCBS (often tied to the Federal Employee Program, FEP) might have an unpublished or state-specific edit not aligned with other BCBS plans. You mentioned it’s not TC (technical component) or 26 (professional component), which rules out split billing, but there could be an obscure rule tied to their claims processing system.
Since you’re doing both components and it’s not TC or 26, the most logical starting point is to bill 72100 without a modifier and confirm Federal BCBS’s specific policy. Here’s what you can do:
Contact Federal BCBS: Call their provider services (look for the number on the back of the patient’s insurance card or on their FEP website) and ask about the exact modifier they’re expecting for global billing of 72100. Mention that you’re performing both the technical and professional components to clarify the context.
Review the Denial/EOB: If you’ve already received a denial, check the explanation of benefits (EOB) or remittance advice for a remark code or note hinting at the required modifier.
Good luck!