BCBS – Claim Editing Update for Modifier 59 Coming Later This Year to Medicare Plus Blue Claims

As communicated in an August Record article, BCBS will begin editing claim lines when modifier 59 is appended on Medicare Plus Blue℠ claims. 

Example of billing scenario:

If you bill modifier 59 and receive a claim line denial, following are some examples of circumstances when it would be appropriate to appeal the denial by submitting medical records that demonstrate the services are separate and distinct:

• CPT code *88360 (Column I) – Morphometric analysis, tumor immunohistochemistry (for example, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual
• CPT code *88342 (Column II) – Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

Modifier 59 may be reported with CPT code *88342 if each procedure is for a different antibody. For example: A needle biopsy is performed on the left breast and an immunohistochemistry antibody stain procedure is performed using GATA3 and a morphometric analysis antibody stain procedure is performed using HER2.

Modifier 59 shouldn’t be used if the same antibody is used for each procedure.

Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.

Source: https://www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/sep/Record_0921v.shtml