The changes, according to Horizon BCBSNJ, are based on the National Correct Coding Initiative guidelines and current industry policy.
After the changes go into effect, Horizon BCBSNJ claim processing systems will recognize services submitted with certain modifiers as “nonstandard” and will reimburse as follows:
• 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/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.
Read the AAPC’s report on the Horizon BCBSNJ modifier payment policy changes.
