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Tips for Using a Modifier with CPT Category II Quality Reporting Codes
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026
Summary
Horizon Blue has clarified that adding modifiers 1P, 2P, 3P, or 8P to CPT Category II quality reporting codes disqualifies practices from receiving credit for quality measures. To receive credit for reviewed-but-not-performed services, report CPT Category II codes WITHOUT these modifiers. This applies to HEDIS reporting and NCQA guidelines.
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What to do
immediately · 5 steps
01Billing and coding team must audit all CPT Category II code submissions to Horizon Blue to ensure modifiers 1P, 2P, 3P, and 8P are NOT appended.
02For quality services reviewed but not performed, report the CPT Category II code alone without modifiers.
03Update billing system rules and encoder settings to prevent automatic attachment of these modifiers to Category II codes.
04Retrain providers and coders on correct modifier usage.
05Review recent claims (past 3 months minimum) for incorrect modifier usage and consider resubmission.
If missed: Failure to comply will result in loss of quality measure credit and potential HEDIS reporting penalties.
Original notice
Tips for Using a Modifier with CPT Category II Quality Reporting Codes
horizonblue.com · Always check the source before changing claims.