E/M Codes Billed with Modifier 52

Effective June 4, 2017 Blue Cross and Blue Shield of Montana implemented new secondary code-auditing software. This software further enhances the auditing of professional and outpatient facility claims for correct coding according to Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT®) and Centers for Medicare & Medicaid Services (CMS) guidelines.

Recently, there has been confusion in the use of Modifier 52 with E/M codes to designate Sports Medicine Physicals. Modifier 52 is not an appropriate descriptor for E/M services. Claims billed for E/M services with a Modifier 52 will deny as V23, The Procedure Code/Modifier combination submitted is not consistent with coding protocols. Patient cannot be billed for the balance resulting from this coding practice.

The AMA described this coding practice by stating, "It would not be appropriate to append modifier -52, reduced services, to a preventive medicine evaluation and management (E&M) service code when only a brief history and examination is performed." Appropriate E/M coding should be reported based on key components outlined by Current Procedural Terminology (CPT) and Health Care Common Procedural Coding System (HCPCS).

For additional information, please refer to your BCBSMT Provider Agreement and AMA billing guidelines.