Clinical editing updates: Modifiers, inappropriate diagnosis combinations

In support of correct coding and payment accuracy, we are providing the information below to keep you informed about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial

Reminder: Anatomical modifiers are required when billing for surgical procedures

Anatomical modifiers identify the specific area of the body where a procedure is performed.

Surgical procedures requiring anatomical modifiers include CPT codes in the range *10000 through *69999 that have a Medicare Physician Fee Schedule bilateral indicator “1,” denoting that the surgical code is eligible to be billed on both sides of the body.

Claims may be denied when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate, but haven’t been appended to the claim line. This applies to professional claims.

Anatomical modifiers required for PCI procedures

Percutaneous coronary intervention, or PCI, is a procedure used to open blocked arteries. PCI codes should be reported with one of the five anatomical PCI modifiers to specify which vessel is being treated. Claims submitted for PCI procedures without one of the coronary vessel modifiers LC, LD, LM, RC or RI may be denied.  

Medicare Plus Blue℠ PPO

Surgical procedure anatomical modifiers on facility claims

Anatomical modifiers will be required when surgical procedures are billed on outpatient facility claims. When an anatomical modifier is missing or incorrect, the claim may be denied. The editing has been in place for professional claims since November 2021. The facility version of this edit was implemented in March 2025.

Reminder: Inappropriate modifier to diagnosis combination

When an ICD-10-CM diagnosis code has a specified anatomical laterality within the code description, the anatomical modifier that is appended to the CPT or HCPCS code must correspond to the laterality within the ICD-10-CM description.

Claim lines may be denied that have a laterality diagnosis submitted with a CPT or HCPCS modifier that doesn’t correspond to the diagnosis code. This applies to professional claims.

Reminder: Inappropriate diagnosis combinations

The current ICD-10-CM official guidelines state, “An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. These conditions are mutually exclusive code combinations.”

Claim lines reported with mutually exclusive code combinations may be denied. This applies to both professional and facility claims.

Blue Care Network commercial and BCN Advantage℠ HMO

E/M services with modifier 25 denied in error

Evaluation and management services with modifier 25 reported with codes *94010 through *94781 are receiving a g33 denial in error. BCN has evaluated the code pair update that took effect in the third quarter of 2024 by the Centers for Medicare & Medicaid Services and has decided to allow modifier 25 to be recognized. Claims denied in error can be resubmitted after March 23, 2025, for reprocessing of payment. Please don’t submit appeals.

BCN Advantage

Modifier JW and JZ

Drug codes that were appropriately reported with modifier JW and JZ that were denied QPL before Feb. 1, 2025, will be reprocessed for payment. The inappropriate denial was updated in our claims system at the end of January.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.