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New edits for billing modifiers 25, 59 and X series


Effective December 1, 2020, we will apply new edits for billing modifiers 25, 59 and X series in New York for fully insured membership claims.  We already apply these same edits for self-insured membership claims. 
 

These new edits are part of our Third Party Claim and Code Review Program and will apply prior to finalizing claims for professional services and outpatient facilities. This is not a clinical review; any edit applied will be based on industry-recognized coding guidelines. We will review the service, service history, changes in condition and diagnostic tests to determine if the services billed with modifiers 25, 59 and X require separate payment. We will allow charges for covered services not subject to the coding review.
 

Find out more about the program.