Fee Navigator®

    Governing Rule: 18


    • 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.

      • It is not acceptable to round the patient's BMI up to 40 for adults or 97% on the pediatric growth curve for patients under 18 years of age in order to claim the higher fee.