BCBS of Illinois Coding and Modifier Issues

BCBS of Illinois Coding and Modifier Issues

In recent weeks, the Illinois Chiropractic Society has received several calls from doctors around the state who were experiencing denial problems from Blue Cross Blue Shield of Illinois (BCBSIL). The problem seemed to center around certain services that require a modifier when billed with other services (i.e. CCI Edits).

In August 2017, BCBS issued a very brief announcement in the Blue Review entitled “Code-Auditing Enhancement.” In the announcement, BCBS said it was implementing “code-auditing enhancement” in the form of software that BCBSIL asserted would help it audit claims by “clinically validating modifiers.” See the release here: https://www.bcbsil.com/pdf/education/bluereview/aug_17.pdf.

Denial Code

After the new claims handling software was installed, some of our doctors began receiving denials on codes that require the 59 or 25 modifiers, even when the doctors had used the modifier code correctly according to CPT® guidelines. The denial code indicated, “The procedure code is inconsistent with the modifier used or a required modifier is missing.” However, in the cases the ICS reviewed, the procedure code and modifiers were billed appropriately, based on the claims information.  It appears that the code-auditing software automatically denies certain claims whenever they contain these modifiers.

Causing additional confusion, the denial code appears to be currently only impacting fully insured BCBS plans. As a result of this disparity, for example, one doctor who submitted identical claims for two different patients (identical codes and modifiers) received a denial in one case and payment in the other.

The ICS has been diligently working with our BCBSIL liaisons and working to gain relevant information on these claim denials.

This week we had lengthy conversations with BCBSIL and our liaisons and have been given the following information:

  • The denials are impacting a small number of providers,
  • According to BCBSIL, this new claim handling “clinical validation” is not specific to chiropractic, but instead is impacting many provider groups,
  • The policy is focused on the 59 and 25 modifiers, and
  • BCBSIL is applying the audit software based on claims processing data analysis that BCBSIL believes demonstrates the doctor has either over-treated or provided care that is not medically necessary.

Although BCBSIL states that this software is applied in a small number of cases, the ICS strongly disagrees with the method that BCBSIL is utilizing to deny these claims. We contend that, except in rare cases, decisions regarding the valid use of these modifiers can only be determined by a medical documentation review.

As a result, we are recommending the following for our doctors who are impacted by this policy and believe the care rendered and billed was medically necessary:

  1. Appeal the specific denial by demonstrating a valid use of the modifier, and
  2. Appeal the denial by pointing to the specific documentation that clearly demonstrates medical necessity.

We believe our doctors will have a greater likelihood of success by appealing BOTH areas because we believe medical necessity is an important underlying component of BCBSIL’s handling of these cases.

The Illinois Chiropractic Society will continue to monitor this program to ensure that BCBSIL is not applying the process in a manner that discriminates against a category of providers.  In the meantime, even if you are in the majority of providers who are not affected by this policy at this time, please remain on alert and review your remittance documents carefully for automatic denials involving modifiers.  The ICS will continue to inform our members of any new information about this issue.

“CPT Copyright 2017 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.”

About Author

ICS Staff

The Illinois Chiropractic Society staff works collaboratively on many topics to bring the most comprehensive and relevant information to our members. We have over 60 years of chiropractic experience and understand the heartbeat of the profession. We all look forward to providing relevant information to our members for years to come.

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