Modifiers

[kayfly]

We have a patient with Anthem BCBS of Illinois I believe...we are in Idaho! I have been for 5 years sending Anthem claims through our local Blue Cross as I was told to do. Suddenly they are telling me this claim has been denied because of not having a modifier. I have never used a modifier with the exception of patients we see with cancer which have been maybe three in all these years. I have no idea which modifier to use in order to get paid. We are a low vision clinic and just have never had the need for a modifier.

[Michele]

You really have two separate issues here:

1.  An out of area BCBS claim  -  which you are correct, in most cases would go to your local.  I say most because there are some unusual situations where this isn't the case, but they are very infrequent.  Since you mentioned that you have been sending them thru your local for several years, that is probably not the issue.  They wouldn't deny a claim sent to the local due to a modifier.  Which brings us to the 2nd issue.

2.  Missing modifier.  Without information on the services billed there is no way for us to tell if a required modifier is missing.  Did you speak to someone?  Or are you just looking at the denial?  It sounds to me like the denial may be incorrect.

[kristin]

I can add this...there is no Anthem of BCBS of Illinois. There is only BCBS of Illinois. Anthem is usually out of California. I am in Illinois, for reference.

We send all our BCBS claims, regardless of state, through the local BCBS, no issue.

As Michele said, cannot provide further issue on denial, without further info. What was billed, exactly? CPT, ICD-10, etc.

[kayfly]

All three codes are retina related: ICD-10 procedure code 99204

Dx codes: H35.3124, H34.8111, H35.353

[Michele]

If the only code being billed is a 99204 then I have no idea what modifier they are looking for.  Do you have a provider rep you can check with?  I would start with that.