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    Governing Rule: 18

    BODY MASS INDEX (BMI)

    • 18.1

      The Body Mass Index (BMI) modifier may be claimed for selected procedures, obstetrical services, anesthesia, second qualified surgeon and surgical assistant services provided in any location when the following criteria are met:

      1. An adult patient has a body mass index of 40 or more.
      2. A patient under 18 years of age who is above the 97th percentile for BMI on an approved pediatric growth curve.
      3. The following HSCs are only eligible for the BMI modifier when the service is provided under general, spinal, epidural anesthetic or regional nerve block performed in an operating room, day surgery or surgical suite: 98.11A, 98.11B, 98.11C, 98.11D, 98.11E, 98.11F, 98.22A, 98.22B.
    • AMA billing tips:

      • BMI modifiers (BMIPRO, BMISRG, BMIANT, BMIANE) should be added to all HSCs that are claimed at the same encounter for patients that have a BMI of 40 or greater.

      • The change to the BMI criteria to make it BMI of 40 affects the adult population ONLY. There HAVE NOT been any changes to the pediatric criteria for BMI. Physicians MAY NOT round a patients BMI up to 40 in order to claim the higher fee, the patients BMI must actually be 40 or greater at the time of the service.

        BMI of 40 applies to all procedures and services that carry the BMI modifier.

        Even though there isn't a BMI modifier on the complex care plan (03.04J) for General Practitioners, the BMI of 40 is used as the definition of obesity for adults.

        It is not acceptable to round the patients BMI up to 40 in order to claim the higher fee. The patients BMI MUST be 40 or greater.