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Modifier 59: Anthem BCBS Rolls Out More Prepayment Audits – 25, 57, RT/LT Affected Too

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Modifier 59: Anthem BCBS Rolls Out More Prepayment Audits – 25, 57, RT/LT Affected Too

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Expect payment processing delays for claims with modifier 59, 25, 57, RT/LT from Anthem BlueCross BlueShield plans. The carrier has now implemented clinical prepayment reviews  in 14 states. October 1 saw the program roll out in 10 new states including New York, Georgia, and Ohio.

You may have several questions on why the insurer has started this scrutiny and the best way to protect your payments. For these answers, read on.

Will X Modifiers Instead of Modifier 59 Avoid Anthem Scrutiny?

While X modifiers were introduced in 2015, most payers including Anthem have not issued official guidance requiring the use of these modifiers rather than modifier 59. Medicare is collecting data on usage of the X modifiers to provide more guidance in the future.

“Modifiers XE, XS, XP, XU were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible.” according to CMS. “

Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, providers may begin using them for claims with dates of service on or after January 1, 2015,” according to the Modifier 59 pdf.

One exception: BlueCross Blue Shield of Rhode Island has issued guidance on this area.”Current Procedural Terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. Providers should utilize the more specific X modifier when appropriate,” according to the BCBS policy.

Why Would Anthem Hold Modifier 59 Claims?

The high error rate has prompted the prepayment audits. Many providers are automatically coding modifier 59 or RT/LT on claims with multiple procedures. Similarly, there is a high error rate for claims with evaluation and management services and a procedure using modifier 25 or 57.

Providers may not be checking that the the National Correct Coding Initiative (NCCI) edits allow a modifier and that the clinical circumstances support using the modifier.

Paying a provider upfront for claims and then having to take back reimbursement is a cumbersome process.

Therefore, Anthem has decided to hold payment until clinical analysts, nurses and coders,  review the claims before approving reimbursement, announced Georgia Anthem BCBS.

How Can I Speed Payment?

Make sure you are using modifier 59 – and the other modifiers – accurately and your claims should process faster. Plus, your compliance will prevent a full scale Medicare audit that can carry a fine of $10,000 per incorrect usage of modifier 59.

**Tool: To help you report modifier 59 compliantly, enjoy 50% off Modifier 59 Expert Report. Use Mod59 at checkout for Printed Hard Copy only. Limited quantities.**

When Should I Use Modifier 59 In General?

Modifier 59 allows you to unbundle — separately report and get paid for — two or more procedures occurring on the same day that would not normally be paid independently. However, this modifier is allowed only when the NCCI edits allow a modifier to override the bundle.

The Anthem clinicians are specifically checking that the CCI edits allow a modifier to bypass a code bundle.

How Do You Know That Codes Are Bundled?

NCCI publishes a quarterly list of codes that CMS for budgetary reasons has denoted as bundled. This may be due to one procedure being typically always inherent or performed in the larger procedure.

The edits indicate the primary procedure (column 1 code) and the secondary (column 2 code). The unbundling modifier goes on the secondary code. You can use a tool to check CCI edits such as First Options offers or get the info right from CMS.

How Do You Know to Use Modifier 59 to Unbundle?

The edits do not specify what modifier to use. You should use modifier 59 only when no other modifier is more appropriate. CMS states that “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

To confirm that modifier 59 is truly the best fit to describe a relationship between multiple procedures, you must check that other modifiers do not apply better.

Modifier 59 informs your carrier that you performed a distinct and independent service from another non-E/M service or procedure performed on the same day. Your documentation must support services that are not ordinarily encountered or performed on the same day by the same individual. To qualify for modifier 59, you must be able to document:

  • different session
  • different procedure or surgery
  • different site or organ system
  • separate incision/excision
  • separate lesion, or separate injury (or area of injury in extensive injuries)

When Should You Apply Modifier 25 Instead of Modifier 59?

The simplest way to avoid confusion between modifiers 59 vs 25 is to remember that you should use 25 only with evaluation and management codes, whereas you should never append 59 to E/M services. Modifier 25 indicates a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Use modifier 25 when an evaluation and management service is significant and separately identifiable from a procedure or other service that was done by the same provider on the same day.

It signifies that the evaluation and management services being submitted for payment went above and beyond that usually associated with a surgical procedure or another evaluation and management service (such as a preventive medicine visit) and should be compensated separately.

Example: A patient presents for a scheduled joint injection into her right knee but in the practice parking lost she falls and hurts her wrist. The physician examines the wrist and administers the knee injection. Using modifier 59 is incorrect in this case because your doctor’s examination of the wrist is considered an evaluation and management code.

Modifier 25 is the correct choice appended to the office visit code such as CPT codes 99212 or 99213 in addition to the code for the knee injection (20610).

Should You Replace Modifier 59 with LT/RT?

Modifiers LT/RT indicate a body side. To show on a claim that the same procedure is performed on different body regions, you may use the body side indicators. 

Example 1: A surgeon excises a lump from the left breast (19120) and performs a needle core biopsy (19100) on the right breast. Excision includes biopsy at the same location (unless further excision was prompted by biopsy results). But when the procedures occur on opposing breasts, you may report them separately, in this case using 19120-LT and 19100-RT, according to the California Medical Association.

Example 2: A patient has multi-joint osteoarthritis and has injections in the right knee joint and left hip joint. Because the physician administers the injections in different joints, the services are not considered bilateral. Modifier 59 is the correct modifier to apply.

Can You Use Modifier 59 for Same Day Surgical Decisions?

When a physician makes a decision during an evaluation and management service for a same day surgical procedure, modifier 57 (Decision for surgery) is the correct modifier.

A pediatrician examines a patient for nurse maid elbow and decides to reduce the radial head. Code 24640 is a minor procedure with 10 global days so you may append modifier 57 to the code to indicate the decision for surgery was made after the evaluation and management service occurred.

When Can I Expect Anthem to Begin Claim Reviews for My State?

Know when to anticipate payment delays on claims with modifier 59, 25, 57 or RT/LT. Here is the list of effective dates for the pre-payment clinical validation review process:

State Start Date
California Medicaid, Medicare Advantage: 9-5-19
Colorado: 9-1-19
Connecticut: 10-1-19
Georgia: 10-1-19
Indiana: 10-1-19
Kentucky: 9-1-19
Kentucky Medicaid: 9-5-19
Maine: 10-1-19
Missouri: 10-1-19
New Hampshire: 10-1-19
New York (Empire BlueCross BlueShield): 10-1-19
New York Medicaid: 9-5-19
Nevada: 9-1-19
Ohio: 10-1-19
Virginia: 10-1-19
Virginia Medicaid (HealthKeepers): 9-5-19
Wisconsin: 10-1-19
Wisconsin Medicare Advantage: 9-5-19

How Can You Train Staff on Modifier Usage? Check Out The Resources Below


Meet Your Writer

Jen Godreau

Content Director

Jennifer Godreau, CPC, CPMA, CPEDC, COPC, has almost 20 years of experience in billing, coding, compliance, and practice management. She develops the content and programs for Healthcare Training Leader, a practice-specific online training company offering step-by-step advice on increasing reimbursement and avoiding compliance violations. Prior to joining Healthcare Training Leader, Jennifer supervised the program delivery for EMRs, practice management systems and compliance and revenue cycle services for more than 6,000 providers. Thousands of software products - encoders, claims management, auditing, and HIPAA compliance, have been created with her teams and helped thousands of practices more easily reduce revenue losses and comply with complex regulations. Her passion for breaking down healthcare rules and requirements in simple steps has provided practical advice, education, and risk reduction strategies to numerous associations, payers and medical specialties especially in primary care, otolaryngology, eye care, and pediatrics. Jennifer’s advocacy resulted in supervision rule revisions, new CPT codes, and CMS compliance contracts. She oversaw the provider auditing and education for one of the major corporate integrity health system settlements. Jennifer has authored and presented on numerous healthcare compliance and payment challenges. Her education guides include the Certified Otolaryngology Coder (CENTC) exam study guide and the AAPC Professional Medical Coding Curriculum. Jennifer has a Bachelor of Arts from Wittenberg University in Springfield, Ohio. She holds certificates in coding, auditing, pediatric coding, and ophthalmology billing and coding, and is AAPC Vice President of the Naples, FL chapter. Please reach out to Jennifer for step-by-step guidance at