Code-Auditing Software Validates Modifiers on Claims

Posted March 23, 2018

In November 2017, an enhancement was made to our code-auditing software to validate modifiers included on claims submitted to Blue Cross and Blue Shield of Illinois (BCBSIL). This enhancement was announced in the August 2017 issue of the Blue Review

According to Current Procedural Terminology (CPT®) coding guidelines, a modifier provides the means to report or indicate that a service or procedure that was performed was affected by some specific circumstance but not necessarily changed per the definition of the code.  

The new logic implemented by BCBSIL in November 2017 assesses modifiers submitted on claims to help confirm appropriate use. 

  • Each review is member-specific and relevant information is compiled to determine if modifiers submitted can be validated.
  • If any modifiers cannot be validated, the claim line will be denied.
  • If the claim line is denied, the provider may use the Claim Inquiry Resolution (CIR) tool, accessible via the AvailityTM web portal, to submit medical records for further review. Providers who do not have online access may use the appropriate claim review form, available in the Forms section.

The information referenced above does not apply to government programs claims. 

CPT copyright 2017 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. 

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.