Tuesday, June 7, 2016

Payment policy for Modifer 59 with colonoscopy procedure 45380 , 45382 and 45386

Policy:

Horizon BCBSNJ will not recognize the application of Modifier 59 when applied to colonoscopy services 45380, 45382, or 45386 when performed with another colonoscopy
service (CPT® code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) on the same date of service for the same patient by the same provider.

Regardless of the application of modifier 59, Horizon BCBSNJ will only consider for reimbursement that colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385,
45386 or 45387) with the highest RVU

CPT code 45381 performed on the same date of service for the same patient by the same provider as another colonoscopy service (CPT code 45380, 45382, 45383, 45384,
45385, 45386 or 45387) and appropriately appended with Modifier 59, will be considered for reimbursement at 50% of Horizon BCBSNJ’s allowance.

Procedure:

Recognize the application of Modifier 59 appropriately appended to CPT code 45381 when billed on the same date of service, for the same patient, by the same provider as another colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) and consider CPT code 45381 for reimbursement at 50% of Horizon BCBSNJ’s applicable allowance.

Do not recognize the application of Modifier 59 for colonoscopy services (CPT code 45380, 45382, or 45386) when billed together with another colonoscopy service (CPT code 45380, 45382, 45383, 45384, 45385, 45386 or 45387) for the same date of service, same patient, by the same provider.


Regardless of the application of modifier 59, Horizon BCBSNJ will only consider for reimbursement that colonoscopy service (CPT code 45380, 45382, 45383, 45384,
45385, 45386 or 45387) with the highest RVU. The other colonoscopy service(s) will not be considered for separate reimbursement but rather will deny as incidental or mutually exclusive to the colonoscopy service considered for reimbursement.

1 comment:

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