Claim Denials When Using Modifiers -25 and -59!

Clean Claims are being “edited” for review by Blue Cross Blue Shield (BCBSIL) of ILL when modifiers -25 and -59 are used. If claim is not validated, the claim for the modifier is denied.

The original procedure should be paid without edit. The edit only applies to modified services when using modifier -25 or modifier -59.

Back in November of 2017, BCBCIL, implemented code-editing software into its claim processing, that validates modifiers included on submitted claims. This focused on Modifiers -25 and -59. This software edit being applied requires a practice to validate the use of the modifier on the claim. Therefore, for denied claims, file for RECONDISERATION with medical records that provide support for the use of the modifier. DO NOT SUBMIT AN “APPEAL” IN THIS CIRCUMSTANCE. Use the online Claim Inquiry. Resolution (CIR) Tool to submit medical records for further review, or print out the Claim Review Form, fill it out and mail it to the address on the form.

If you are an ISMS member, you can contact the ISMS Advocacy Team by calling 800-782-4767 Ext. 1470.

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