Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Modifiers)
MOD Description Submission Guidelines Impact to Payment
-QJ Services/items
provided to a
prisoner or
patient in state or
local custody,
however the
state or local
government, as
applicable, meets
the requirements
in 42 CFR 411.4
(B)
-QK Medical
direction (by
physician) of
two, three or
four concurrent
procedures by
qualified
personnel
-QS Monitored
anesthesia care
service
-QX CRNA service
with medical
direction by a
physician
-QY Medical
direction of one
Certified
Registered Nurse
Anesthetist
(CRNA) by an
anesthesiologist
11-14
The appropriate use of this modifier is
required for our Government Program and
Public Program subscribers.
The –QJ may be submitted for other
subscribers/products as well, but the
modifier will not affect adjudication.
Append the modifier when the
anesthesiologist supervises more than four
concurrent anesthesia procedures. The
anesthesiologist may perform the induction
and emergence but may not be present
during the entire operative session.
Append the modifier when the
anesthesiologist provides specific
anesthesia services to a particular patient
undergoing a planned procedure including
performing a preanesthetic examination, be
physically present in the operating suite,
monitors the patient’s condition, and is
prepared to furnish anesthesia services as
necessary.
Append the modifier on the CRNA charges
when the anesthesiologist supervises the
CRNA who performed the anesthesia
procedure. The anesthesiologist may
perform the induction and emergence but
may not be present during the entire
operative session.
Append the modifier on the
anesthesiologist charges when the
anesthesiologist supervises the CRNA who
performed the anesthesia procedure. The
anesthesiologist may perform the induction
and emergence but may not be present
during the entire operative session.
Services or items will
deny for Government
Program or Public
Program subscribers.
Payment is made at
the part-time
anesthesia conversion
rate.
Payment is made at
the part-time
anesthesia conversion
rate. Only one –QS
service per day will
be allowed.
Payment is made at
the part-time
anesthesia conversion
rate.
Payment is made at
the part-time
anesthesia conversion
rate.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (10/05/11)