Clinical editing updates: Prostate specimen re-bundle, biopsy specimen analysis; postpartum, global delivery; modifier 79; preadmission tests; place of service; anatomical modifiers; telehealth; code G2211

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

Prostate specimen re-bundle

In June 2024, we communicated that Blue Cross commercial would be introducing a new edit starting Sept. 9, 2024, for prostate specimen re-bundling that would require code G0416 to be billed for prostate biopsies instead of *88305. After further consideration, we’ve decided not to implement this policy. This applies to professional and facility claims.

Prostate biopsy specimen analysis

We previously implemented editing for a prostate biopsy specimen analysis laboratory policy. Due to a system issue, editing for this policy hasn’t been enforced. The system issue has been fixed and editing on this policy resumed in April 2025. This applies to professional and facility claims.

Reminder: Postpartum and global delivery

Most delivery codes (for example, *59400 and *59510) already include postpartum care as part of the global service.

It’s not appropriate to bill separate evaluation and management, or E/M, codes during the postpartum period. E/M services submitted during the postpartum period may be denied if the service is maternity-related. 

Unrelated E/M codes that require separate evaluation and management are allowed with the appropriate modifier. This applies to professional claims.

Reminder: Modifier 79

Modifier 79 is used to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.

If no global procedure code was previously performed or billed for the member, the current claim with modifier 79 may not be reimbursed as this is inappropriate usage of modifier 79.

This applies to professional claims.

Modifier 79 description: Performance of a procedure or service during the postoperative period was unrelated to the original procedure.

Reminder: Preadmission tests

Blue Cross payment policy requires diagnosis-related group reimbursed hospitals to include all preadmission testing, given up to seven days before admission, on the inpatient claim.

Claims submitted for preadmission testing services within seven days of a related inpatient stay may be denied if billed separately.

If the inpatient claim has already been submitted without the preadmission tests, submit a corrected claim using type of bill 117 to replace the previous claim.

This applies to facility claims.

Reminder: Bill claims with correct place of service

Select services have separate rates for physician services when given in facility and non-facility settings. The place of service submitted on a claim should reflect the setting the service was given. Claims submitted with an incorrect place of service may be denied. This applies to professional claims.

Medicare Plus Blue℠

Radiology procedures requiring anatomical modifiers

Correct coding guidelines regarding anatomical modifiers are important. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations and potentially unnecessary medical record review.

In May 2025, Medicare Plue Blue implemented an edit that denies radiology procedure codes requiring anatomical modifiers when the modifier isn’t present. Radiology codes with descriptors that don’t support the use of an anatomical modifier are exempt.

The following are omitted modifiers affected by this edit:

• LT (left side)
• RT (right side)
• 50 (bilateral)
• E1-E4 (eyelids)
• FA-F9 (fingers)
• TA-T9 (toes)
• LC (left circumflex, coronary artery)
• LD (left anterior descending coronary artery)
• LM (left main coronary artery)
• RC (right coronary artery)
• RI (ramus intermedius)

If a provider receives a denial for a missing anatomical modifier, an appeal isn’t required. The radiology procedure can be resubmitted with the appropriate anatomical modifier for payment reconsideration.
This applies to professional and outpatient facility claims.

Blue Care Network commercial

Telehealth

Effective July 1, 2025, telehealth E/M procedure codes *98000, *98001, *98002, *98003, *98004, *98005, *98006, *98007, *98008, *98009, *98010, *98011, *98012, *98013, *98014 and *98015 will only be allowed when billed with place of service 02 or 10. Telehealth E/M procedure codes submitted without a telehealth place of service will be denied.

Telehealth modifiers 93, 95, GT or FQ aren’t required for the telehealth E/M procedure codes.

Also effective July 1, 2025, E/M procedure codes *99202, *99203, *99204, *99205, *99212, *99213, *99214 and *99215 billed with telehealth place of service 02 or 10 or telehealth modifiers 93, 95, GT or FQ will deny as provider liability.

This applies to professional claims.

BCN Advantage℠

Office, outpatient E/M visit complexity add-on code G2211

The Centers for Medicare & Medicaid Services added information on how to use G2211 with modifier 25 for certain Medicare Part B services starting Jan. 1, 2025. BCN Advantage is aware of the update and has worked diligently to update the system to accommodate these changes. System updates were finalized in May 2025. This applies to professional claims.

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.