NJ BCBS Changes Physician Reimbursement for Modifiers

Blue Cross Blue ShieldEffective June 1, 2015, BCBSNJ will make changes to their reimbursement policies for modifiers 52, 53, 54, 55, 56, and 73. The purpose of this policy is to provide guidelines for the reimbursement of eligible services appropriately appended with modifiers for participating and non-participating professional providers.

All BCBSNJ products are included in the modifier policies, except products where Horizon BCBSNJ is secondary to Medicare (i.e. Medigap). All insured and ASO accounts are included.
All Modifiers will not provide for reimbursement of an ineligible service. No additional reimbursement will be issued if the reimbursement to the physician is via capitation or if reimbursement for such services is captured in a global rate.

Modifier 52 – Reduced Services
Used for reporting reduced services when the procedure was terminated after the patient was prepped and was in the room where the service was to be performed.

Policy: Horizon will reimburse reduced services appropriately appended with modifier 52 at 50 percent of the applicable Horizon BCBSNJ fee schedule amount.

Modifier 53 – Discontinued Services
Used to indicate that the physician terminated a surgical/diagnostic procedure due to the patient’s well-being.

Policy: Horizon BCBSNJ will reimburse discontinued procedures appropriately appended with modifier 53 at 25 percent of the applicable Horizon BCBSNJ fee schedule amount.

Modifier 54 – Surgical Care Only
Used for surgical care only when a qualified health care professional performs the surgical procedure and another provides the preoperative and/or postoperative care.

Policy:  Horizon BCBSNJ will reimburse surgical care services appropriately appended with modifier 54 at 75 percent of the applicable Horizon BCBSNJ fee schedule amount.

Modifier 55 – Postoperative Management Only
Used for postoperative management only when a qualified healthcare professional provides postoperative care and another performed the surgical procedure.

Policy: Horizon BCBSNJ will reimburse postoperative management services appropriately appended with Modifier 55 at 15 percent of the applicable Horizon BCBSNJ fee schedule amount.

Modifier 56 – Preoperative Management Only
Used for preoperative management only when a qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure.

Policy: Horizon BCBSNJ will reimburse preoperative management services appropriately appended with modifier 56 at 10 percent of the applicable Horizon BCBSNJ fee schedule amount.

Modifier 73 – Discontinued outpatient hospital or ASC Procedures Performed Prior to Administration of Anesthesia
Used when an outpatient/hospital ambulatory surgery center procedure is stopped prior to the administration of anesthesia.


Policy: Horizon BCBSNJ will reimburse discontinued outpatient hospital or ambulatory surgery center procedures performed prior to the administration of anesthesia services appropriately appended with Modifier 73 at 50 percent of the applicable Horizon BCBSNJ fee schedule amount.

More information on these modifier policies please click here.

Join Our Newsletter

Get Updates Direct to Your Inbox. Gain access to a rich library of articles, white papers, webinars, podcasts and more. Register today to receive eMDs Insights newsletter.

*
*
*
*
Specialty *
State *