When you bill for distinct, separate procedures, it’s crucial to know which modifiers will ensure full payment for each service. Modifier 59, “Distinct Procedural Service,” acts as a universal tool to unbundle procedures that are typically included in a larger procedure or “bundled” together.
This modifier signals to the payer that specific circumstances justify separate billing and payment for the unbundled code. Such circumstances generally include:
- Separate Encounters on the Same Day: If procedures were performed during different patient visits on the same day.
- Different Anatomic Sites or Body Systems: If procedures were done on distinct body parts or organs during a single encounter.
- Sequential, Timed Procedures: If procedures were carried out consecutively and took a significant amount of time.
- Diagnostic-Therapeutic Relationship: If a diagnostic procedure preceded and led to a therapeutic procedure.
- Unplanned Diagnostic Follow-up: If an unexpected diagnostic procedure was necessary after a therapeutic procedure.
Modifier 59: Precision is Key to Avoid Denials
Claims are processed automatically, without direct review by a physician. Payers rely on the accuracy of the submitted information, assuming that proper documentation exists to support the claim. Unfortunately, Modifier 59 is often misused. As a consequence, some payers now routinely deny claims that include this modifier. This forces providers to appeal denials and submit supporting documentation to justify the use of Modifier 59.
This denial and appeal process is burdensome for both providers and payers. It delays payments and requires additional work from both parties, including writing appeals and reviewing documentation.
New Modifiers to Replace Modifier 59
The Centers for Medicare & Medicaid Services (CMS) has introduced four new modifiers, designated as X[ESPU], to provide more specific reasons for unbundling codes:
- XE: Separate Encounter
- XS: Separate Structure
- XP: Separate Practitioner
- XU: Unusual Non-Overlapping Service
These modifiers are applicable to Medicare Part B claims. Some commercial insurers, like Horizon Blue Cross Blue Shield of New Jersey, have also indicated their intention to accept these X[ESPU] modifiers.
While CMS continues to accept Modifier 59, it’s not mandatory to use the new X[ESPU] modifiers. However, it’s prudent to be aware of these new modifiers and use them appropriately. Overusing Modifier 59 could lead to audits from Medicare Part B carriers.
To ensure accurate billing, carefully review documentation and determine if the specific circumstances warrant the use of a particular X[ESPU] modifier. Let’s explore some examples of when each of these modifiers should be used.
Modifier XE: Separate Encounter
Modifier XE indicates that a service was performed during a separate encounter on the same date of service as a bundled procedure.
Example:
A patient visits an otolaryngologist in the morning for an evaluation and management (E/M) visit. During the visit, the doctor performs a diagnostic nasal endoscopy. The codes for this visit are:
- 99213-25: Office or other outpatient visit for the evaluation and management of an established patient.
- 31231: Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
Later that evening, the patient experiences a severe nosebleed and goes to the emergency room (ER). The ER physician calls the otolaryngologist, who comes to the ER and performs a complex procedure to control the nasal hemorrhage. This ER visit is coded:
- 30903: Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
CPT code 30903 is bundled with 31231, meaning they cannot be billed separately. However, by appending Modifier XE to 30903, the provider indicates that the ER procedure was a distinct service performed during a separate encounter from the earlier nasal endoscopy. This allows for separate billing and reimbursement for both procedures.
Modifier XS: Separate Structure
Modifier XS indicates that a procedure was performed on a separate organ or structure from a bundled procedure.
Example:
A patient visits an orthopedist for two procedures: a knee injection with ultrasound guidance on the left knee and an aspiration of the right knee without ultrasound guidance.
The coding for these procedures is:
- 20611-LT: Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting – Left side
- 20610-XS-RT: Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance – Right side
While modifiers LT and RT typically indicate procedures performed on different sides of the body, not all payers accept these modifiers to break a bundle. In this case, Modifier XS or Modifier 59 is necessary to signal to the payer that the two procedures are distinct and should be billed separately.
Modifier XP: Separate Practitioner
Modifier XP indicates that a service was performed by a different practitioner than the one who performed the primary procedure.
Example:
A colorectal surgeon performs a partial colectomy (CPT code 44147), while another surgeon in the group performs a regional abdominal lymphadenectomy (CPT code +38747). Although +38747 is typically bundled with 44147, the fact that a different surgeon performed the lymphadenectomy allows for separate billing. By appending Modifier XP to 38747, the provider indicates that the procedure was performed by a separate practitioner.
Modifier XU: Unusual Non-Overlapping Service
Modifier XU signifies that a service is distinct and does not overlap with the usual components of the main procedure.
Example:
An otolaryngologist performs a rigid diagnostic nasal endoscopy to evaluate nasal complaints. The physician then switches to a flexible laryngoscope to assess the patient’s cough, throat clearing, and swallowing difficulties.
Typically, a nasal endoscopy and a flexible laryngoscopy are not both billed during a single encounter, as a single scope can often be used for both procedures. However, in this case, the use of two separate scopes and the distinct nature of the procedures justify separate billing. By appending Modifier XU to 31231 (nasal endoscopy), the provider indicates that the nasal endoscopy was performed using a separate scope and did not overlap with the laryngoscopy.
CMS Simplifies Modifier Processing for Unbundled Procedures
The Problem:
Previously, CMS only recognized certain modifiers (59, XE, XS, XP, and XU) when they were applied to the second code (Column 2) in a bundled pair of procedures. This often led to claim denials, especially when the modifier was applied to the first code (Column 1), even if it was the correct procedure to modify.
The Solution:
To streamline the claims process and reduce denials, CMS implemented a new rule effective. This rule allows for separate procedure modifiers to be applied to either the first or second code in a bundled pair. This means that the modifier will be recognized, and the claim will be processed correctly, regardless of its position.
Why This Matters:
- Reduced Claim Denials: By allowing more flexibility in modifier placement, the new rule minimizes the risk of claim denials due to incorrect modifier usage.
- Simplified Billing: Billers can now focus on accurately identifying the correct modifier and applying it to the appropriate code, without worrying about its position in the claim.
- Improved Efficiency: Fewer claim denials and rejections lead to faster payment processing and reduced administrative burdens for both providers and payers.
Example:
In the XU modifier example, the claim can now be coded as 31231, 31575-XU, ensuring that the modifier is recognized and the claim is processed correctly.
How to Use Modifier 59 Effectively to Avoid Claim Denials:
Modifier 59 is a crucial tool for medical coding companies to prevent claim denials. It signals to payers that separate procedures were performed, even if they seem bundled. To use it effectively, ensure:
- Clear Documentation: Detailed medical records are essential to justify the use of Modifier 59. Document the distinct nature of procedures, different anatomic sites, separate encounters, or significant time intervals.
- Accurate Code Pairing: Pair Modifier 59 with the appropriate CPT code to accurately represent the service provided.
- Payer-Specific Guidelines: Understand each payer’s specific rules and guidelines regarding Modifier 59 usage. Some payers may have specific criteria or limitations.
- Regular Training: Keep your coding staff updated on the latest guidelines and best practices for using Modifier 59. Regular training sessions can minimize errors and ensure compliance.
- Claim Review Process: Implement a robust claim review process to identify potential issues before submission. This proactive approach can help catch errors and prevent denials.
By following these guidelines, medical coding companies can significantly reduce claim denials and improve revenue cycle management.