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BCBSIL Will Automatically 'Edit' ANY Claim with Modifiers -25 and -59 for Review
Posted on: 7/3/2018

ISMS is hearing from some members that clean claims are being automatically "edited" by Blue Cross and Blue Shield of Illinois (BCBSIL) for services when modifiers -25 and -59 are used. 

Beginning in November 2017, BCBSIL implemented code auditing software into its claim processing logic that validates modifiers included on submitted claims. This change is focused on modifiers -25 and -59.

What this means for health care professionals is that BCBSIL will automatically edit any claim that is submitted with modifiers -25 or -59 for review. If the claim cannot be validated and appears to be used incorrectly, the claim for the modifier will be denied. The original procedure should be paid without edit. The edit only applies to modified services – modifier -25 and modifier -59.

Because the software edit that is being applied requires a practice to validate the use of the modifier on the claim, you should submit medical records that provide support for the use of the modifier for reconsideration. 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, complete and mail to the address on the form.

It is our understanding that if you send in the supporting data to BCBSIL for review and it is deemed appropriate, the modifier claim will be released for payment.

ISMS will be meeting with representatives of BCBSIL later this month to discuss this issue and advocate for fair billing practices. We will report back to you concerning the outcome.

Questions? Contact ISMS’ advocacy team at 800-782-4767 ext. 1470, or by email

ISMS resource

You can also access our Issue Brief, Modifier -25. This resource addresses the Centers for Medicare and Medicaid Services/National Government Services policies on the use of modifier -25 to identify a significant and separate identifiable evaluation and management (E/M) service  provided during the same encounter as a minor procedure. Some private payer policies may vary slightly. ISMS is also developing an Issue Brief on Modifier -59; watch for its publication via Physician Advocate and www.isms.org.

As a member benefit, the Issue Brief is password protected. If you need to request a username and password, contact online support at 888-476-7776 or onlinehelp@isms.org between 8:30 a.m. and 4:45 p.m. After-hours requests are answered promptly the next business day. You may also register online or retrieve your username or password.



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