BCBS Modifier Denial Update

Many chiropractic physicians around the State of Illinois have been receiving denials from BlueCross BlueShield of Illinois (BCBSIL) for services rendered and billed with modifiers 25 or 59 (including XE, XS, XP, XU). The Illinois Chiropractic Society informed doctors about BCBSIL’s announced claim processing change in December, and we have been working diligently on this ongoing issue since early December.  Because of its importance to the ICS and its members, we want to share our updated efforts and information.

Background

In November 2017, BCBSIL instituted a claims processing protocol — “code-auditing enhancement” via “clinically validating modifiers” — that began denying some providers’ claims on codes that require the modifiers 25 or 59 (including XE, XS, XP, XU). After making initial contact with BCBSIL regarding the change, we had been informed that the change would only impact a small number of providers; that it would impact several provider groups; and that BCBSIL was using claims processing data analysis to identify the providers to whom the protocol was applied.

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Since the inception of the new protocol, providers and patients continue to receive denials in increasing numbers.  The EOBs cite a denial code that states: “The procedure code is inconsistent with the modifier used or a required modifier is missing…” However, these claims are being denied on submission, with no request for or review of documentation to determine the appropriateness of the denials.  In the cases we have seen, the procedure codes are consistent with the modifier used, and modifiers are not missing; in fact, their presence has triggered the denials.

Since December, based on the volume of calls to the ICS, it appears that this “code-auditing enhancement” via “clinically validating modifiers” is impacting the majority of chiropractic physicians in Illinois who are participating providers with BCBSIL. The ICS continues to strongly disagree with the method that BCBSIL is utilizing to deny these claims. We also contend that, except in rare cases, decisions regarding the valid use of these modifiers can only be determined by a medical documentation review.

Although some members have asked if this policy impacts only chiropractic physicians, we are finding that the denials are impacting several other provider groups, including medical doctors and physical therapists. We are in discussions with several associations that represent health care providers around Illinois.

Previous and Ongoing Actions

The Illinois Chiropractic Society has been in contact with BCBSIL at various levels through our liaison, and we anticipate meeting with BCBSIL in the coming weeks. In addition to extensive research and conversations with doctors around the state, we have also been in contact with national associations, attorneys, Certified Professional Coders, compliance experts, and many others regarding the denials and billing practices. This problem is our number one priority at this time.

The ICS has not ruled out any of our potential options for both current and future actions. However, we are currently working persistently on a diplomatic solution, as we understand the serious impact of the situation.

Current Recommendation

We have received information from providers across the state indicating the various steps that doctors are taking.  Each of the actions has had varying results for different doctors. Based on the information provided by our doctors and our ongoing diplomatic efforts, we believe providers should open a claim inquiry for all denials. Although we understand this process is time-consuming, we believe that obtaining a series of positive claims resolutions provides the greatest likelihood for our doctors to be exempted from BCBSIL’s ongoing modifier code audit program.

Here are the steps for filing a claim inquiry with BCBSIL:

1. Use Availity to open Refund Management – eRM. 
2. Click on the Claim Inquiry Resolution tab.
3. Click Create New Claim Inquiry button immediately under the list of previous claims inquiries.
4. Fill out the form selecting the reason option labeled “Additional Information.”
5. Attach medical records (documentation) for the corresponding date of service as an attachment.
6. Instead of attaching an appeal letter, we recommend that you use the comment section to write your appeal. Your appeal should include the following information, as appropriate:
   1. Modifier 59 (including XE, XS, XP, XU) with 97140 – Indicate the type of manual therapy (i.e., myofascial release, trigger point, manual lymphatic drainage, etc.) provided was applied to a separate anatomic site than that of the chiropractic manipulative treatment. Also indicate that modifier 59 (or XE, XS, XP, XU) was applied appropriately to demonstrate the procedure is distinct and independent from 9894x. Then request that the claim be reviewed and processed for payment according to the beneficiary’s benefit plan. (See Note 1 below)
   2. Modifier 59 (including XE, XS, XP, XU) with 97110-97124– Indicate that the type of therapy provided represents distinctly separate and unrelated procedures that do not include CMT. Also indicate that modifier 59 (or XE, XS, XP, XU) was applied appropriately to demonstrate the procedure is distinct and independent from 9894x. Then request that the claim be reviewed and processed for payment according to the beneficiary’s benefit plan. (See Note 2 below)
   3. Modifier 25 – Indicate the examination performed was at a level higher than the “pre-manipulation patient assessment” included in the chiropractic manipulative treatment and requires evaluation and management “service above and beyond the usual preservice and post-service work associated with” 9894x. Then request that the claim be reviewed and processed for payment according to the beneficiary’s benefit plan. (See Note 3 below)

When successful

Providers have found that the payments are received 30-45 days after claim inquiry is opened through eRM. However, not all doctors have been successful when utilizing this method. Of course, regardless of whether you follow this action, BCBSIL may still provide an adverse determination on individual cases, depending on other factors.

Although we understand that this is not the ideal solution for this situation, we believe it is the best solution based on what we know today. As soon as we have additional information on this problem, we will notify chiropractic physicians through a special email release or the Illinois Practice Edge. Please encourage your colleagues to subscribe to our email notices here: https://ilchiro.org.

Note 1:

Based on CPT® Guidelines and additional information supplied by CPT® Assistant, the 97140, 9894x, and 59 modifier combination requires that the 97140 service is performed on a separate anatomical body region. CPT® Guidelines list regions specific to CMT as follows: “cervical region, (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region.  The five extraspinal regions referred to are head (including temporomandibular joint, excluding alanto-occipital) region; lower extremities: rib cage: (excluding costotransverse and costovertebral joints) and abdomen.” Additionally, when BCBSIL reviews the claim inquiry, BCBSIL will also review the total units and may then deny the care for medical necessity, because proving and documenting medical necessity for multiple units of 97140 can be challenging. Additionally, we are encouraging providers to be certain to bill the CPT® code that most closely resembles the service being provided. We have found that, occasionally, providers bill 97140 when actually rendering massage therapy (97124).

Note 2:

Based on CPT® Guidelines and additional information supplied by CPT® Assistant, the 97110-97124, 9894x, and 59 modifier combination does NOT require that the therapy service be performed on a separate anatomical body region. However, when making the inquiry, BCBSIL will also review the total units and may then deny multiple units, because proving and documenting medical necessity for multiple units of 97110-97124 can be challenging.

Note 3:

CPT® guidelines clearly indicate that E/M codes can be billed with a 9894x on the same date of service with a modifier 25. Additionally, the guidelines say that different diagnoses are not required when using the 25 modifier.  When reviewing the claim inquiry, BCBSIL will also review the level of the exam billed to see if it is supported by the information in the documentation. We also anticipate BCBSIL will review the frequency of the exam as compared to standard of care, BSBSIL’s re-exam guidelines, and the amount of time since the most recently billed E/M.

Sources: CPT® Guidelines, CPT® Assistant (October 2009, November 2016)

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