Certain modifiers for outpatient claims will receive prepayment coding review

Beginning April 1, 2025, we will update our prepayment coding validation review process for outpatient claims to include claims submitted with modifiers 24, 25, 58, 59, 78, 79, E1–E4, F1–F9, TA, LT, RT, LC, LD, RC, LM, RI, XE, XP, XS, and XU.

This updated review aligns with published reimbursement policies and National Correct Coding Initiative (NCCI) correct coding guidelines that require proper modifier usage and submission. We will evaluate the use of modifiers in conjunction with the edits they bypass (such as the NCCI). Registered nurses and coders who are clinical analysts will review claims pending validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.

If you believe a claim reimbursement decision should be reviewed, please follow the claims payment dispute process outlined in your provider manual, which is available in our provider manual.