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CPT 28485 Modifier Denial

C

conroefoot

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Location
Conroe, TX
We are having issues getting CPT 28485 for QTY: 1 Unit paid by BCBS TX /BCBS Health Select.

Background Info: Patient has displaced Second metatarsal fracture right foot. Provider states surgery is necessary. ORIF Second Metatarsal right foot (QTY: 1 Fracture).


Our Submitted Claim Lines Read:

CPT: 28485 | Mod: RT | Description: Open treatment of metatarsal fracture, includes internal fixation, when performed, each open treatment of metatarsal fracture, includes internal fixation, when performed, each ORIF metatarsal | Diagnosis: S92.321A | Units: 1


Both BCBS plans are denying the claims with denial code C04: "the procedure code is inconsistent with the modifier used, or a required modifier is missing."


Is anyone else experiencing this issue with BCBS? We have submitted the claims with the rt modifier, which is correct for single units, so I’m curious if anyone else has encountered this denial or found a solution. This issue started around June 2026 on one or two patients and now we are seeing an increase in denials. Called BCBS and they said do an appeal, which we have done multiple times and we still get a denial.


Any insight would be appreciated!
 
Have you tried the T mod? It is not technically correct to use on MT but sometimes that is the problem. Or just take the mod off. They could have a processing issue internally incorrectly doing this. Also, make sure someone did not accidentally do a mismatch between the dx laterality and the mod.
Was there anything else done at the same time or only the ORIF?
Probably has something to do with the updates around that time: https://www.bcbstx.com/provider/edu...-editing-rules-to-be-implemented-in-july-2026

 
Thank you for responding!

Also tried it with the T6 Modifier, and no modifier at all. Both denied. The only service that was rendered was the 28485. Even called surgery center to see how they billed and if they recieved payment. They did 28485 RT and got paid. I've done multiple appeals and have called BCBS and they tell me all I can do is appeal again. SO FRUSTRATING!
 
Were they in a global for something else? Did someone accidentally try to bill an assistant claim and not put the AS and that already went through and now the surgeon claim is denying? Not that AS is allowed for this but I have seen that happen. Is the unit only 1? Other than that, something is probably wrong w/ their claim edits.
Can you do a reconsideration instead of an appeal? Otherwise, escalate it to your provider network rep. Especially if there is more than one and it is continuous since a certain date, give them a spreadsheet.
 
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