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Enhanced claim edits for modifiers
June 1, 2022

This article is for all providers caring for our members

Effective July 18, 2022, we will enhance our claims editing system to improve its overall accuracy regarding modifier usage. Currently, some modifiers including, but not limited to, 25, 59 (X-EPSU subset), 79, and 24 are inappropriately overriding unbundling edits in certain situations. Based on an extensive assessment of modifier use, the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) have advised the use of pre-payment modifier review based on claim details and patient claim history.

Consistent with the recommendations of the OIG and CMS, Blue Cross will implement enhanced editing based on national guidelines for modifier usage. As part of this process, registered nurses with coding certifications will look at claim data in conjunction with patient claim history to confirm appropriate modifier use.

You can review guidelines for correct modifier use in:

  • The Current Procedural Terminology (CPT) and Coding with Modifiers manuals, published by the American Medical Association
  • The Correct Coding Initiative (CCI) and CMS claims processing manuals, published by the Centers for Medicare & Medicaid Services

Upon implementation of our enhanced editing system, you may submit an appeal with the appropriate medical records and documentation to support modifier use.


If you have any questions, please call Network Management and Credentialing Services at
1-800-316-BLUE (2583). As always, thank you for the care you provide to our members.