Modifier Reimbursement Changes Effective January 1

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is implementing policy to align with the Centers for Medicare & Medicaid Services (CMS) and correct coding initiatives. Effective January 1, Blue Cross NC will reimburse as follows:

Unplanned return to surgery services:

Services submitted with a 78 modifier will receive 70% of the allowed reimbursement. Please review the commercial reimbursement policy for unplanned return surgery (PDF) for additional information.

Discontinued services:

Services submitted with a 53 or 73 modifier will receive 50% of the allowed reimbursement. Please review the commercial reimbursement policy for discontinued procedures (PDF) for additional information.

Split Surgical Package:

Blue Cross NC will reduce reimbursement for services filed with modifier 54, 55, and 56.

• Services submitted with a 54 modifier will receive 70% of the allowed reimbursement.
• Services submitted with a 55 modifier will receive 20% of the allowed reimbursement.
• Services submitted with a 56 modifier will receive 10% of the allowed reimbursement

Emergency specialty physicians performing surgical procedures in place of service 23 (emergency room) will receive 70% of the allowed reimbursement, with or without modifier 54. Emergency physicians who provide follow-up services for surgical procedures performed in emergency departments are encouraged to file the appropriate level of evaluation and management (E&M) code.

These reimbursement requirements will apply to all commercial, Administrative Services Only (ASO) and Blue Card Inter-Plan Program Host members. This policy does not apply to Blue Cross NC members who seek care in other states. For additional information, please review the commercial reimbursement policy for split surgical package (PDF).