CommercialAdministrativeMedium impact
Updated submission requirements for claims using Modifier 59 and X
Blue Cross Blue Shield of Rhode Island·RI · Gastroenterology·Physician / Behavioral Health
Effective date
May 1, 2019
We identified it
Jun 20, 2026
Summary
BCBSRI has removed CPT codes 43239 (EGD with biopsy) and 45380 (colonoscopy with biopsy) from pre-payment review requirements when used with Modifier 59 or X modifiers, effective May 1, 2019. Medical records no longer need to be submitted for these codes, but proper documentation must still be maintained and NCCI edits verified before claim submission.
Action Required
Immediately: Billing team should update procedures to no longer submit medical records for CPT 43239 and 45380 when using Modifier 59 or X modifiers (XE, XP, XS, XU) for BCBSRI claims. Continue to verify NCCI edits exist before submission and ensure documentation supports modifier use. Providers must maintain proper documentation in medical records as post-payment reviews may still occur.