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Modifier Coding Alert

Modifier Guidance:

Look at Published X{ESPU} Examples Some Payers Are Offering, Part 1

Now you have guidance from Moda Health to better equip yourself to pick a new modifier over 59.

Since CMS introduced four new X modifiers on Aug. 15, 2014 to lighten modifier 59’s load, most coders have been holding their breath in anticipation of more clarifying information than just the modifiers’ descriptions. There are examples of all four to help you understand when you’ll use each one.

Read the scenarios here so that you can add each modifier into your repertoire for coding your separate services. Watch for part two of this series in the next issue of Modifier Coding Alert to see three more payer examples.

Relate These Examples to Your Coding Issues

Several Medicare administrative contractors (MACs) are providing similar scenarios explaining how and when you should use each of the following four new X modifiers:

  • XE (Separate encounter)
  • XP (Separate practitioner)
  • XS (Separate structure)
  • XU (Unusual non-overlapping service).

Let’s focus on one MAC’s published policy. Compare Moda Health examples below to situations where you would normally think to use modifier 59 (Distinct procedural services). Then apply the correct XE, XP, XS, or XU instead.

Get to Know Modifier XE

As the descriptor implies, you use modifier XE when coding for separate encounters on the same day by the same provider.

Example: Your doctor performs a surgical procedure at 8 a.m., and then performs a second, separate surgical procedure in the afternoon on the same date of service. According to Moda Health, you should apply modifier XE in this situation.

“[This] example is very clear,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. “Your physician should make it clear in the documentation that the services were performed at different times of the day and there was medical necessity.”

Match XP to More Than One Physician

Moda Health states in their reimbursement policy that they find modifier XP a little unclear, but that you may use modifier XP for the same encounter, at the same facility, with different provider specialists.

Example: According to Moda Health, “one possible [modifier XP] scenario might be” when your family practice physician sees a patient in the office. During the visit, she encounters a problem and requests the help of a specialist physician. Your coding includes both physicians on the one claim, so you use XP on the second provider’s services.

Single Out XS for Use with Structures

Modifier XS’s descriptor states that you attach it for separate procedures due to “separate structures.” Unfortunately, there is no clear guidance on what constitutes a separate structure.

Example: Your physician provides an injection in the patient’s right ankle (20550, Injection[s]; single tendon sheath, or ligament, aponeurosis [eg, plantar “fascia”]) to treat tendonitis. He then does a second injection into the left ankle (again, 20550). This is the same encounter in different anatomical sites and contralateral structure so, according to Moda Health, you would attach modifier XS to the second line 20550.

The problem: Not all experts believe this example is an accurate illustration of how to use modifier XS.

“Although the XS modifier’s meaning is ‘separate structure, a service that is distinct because it was performed on a separate organ/structure,’ this is not the appropriate modifier for this example,” says Candice Ruffing, CPC, CPMA, CPB, CENTC, at Acevedo Consulting Inc. in Delray Beach, Fla. “CPT® code 20550 is a unilateral procedure and therefore modifier 50 (Bilateral procedure) would be the appropriate modifier. One injection was performed on the right ankle and another injection was performed on the left ankle. Keep in mind that the X{EPSU} modifiers are a subset to modifier 59.” According to Ruffing, you should use modifier XS on the column 2 procedure code in the Correct Coding Initiative (CCI) file.

Note: In a case of separate injuries or areas of injury, Moda Health believes that either XS or 59 may be appropriate depending on the specific circumstance.

Nail Down Modifier XU

Modifier XU seems to be the most confusing new modifier for most coders because there has not been any clarification on what qualifies as “unusual, overlapping services.” Even the Moda Health policy offers a somewhat unclear example for XU.

Example: Your doctor performs a diagnostic cardiac angiography procedure (93563, Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately in addition to code for primary procedure)) on a patient. Due to the findings, your physician makes a decision to perform a therapeutic angioplasty surgical procedure (35452, Transluminal balloon angioplasty, open; aortic). This may or may not occur in the same procedure room during the same session/encounter.

Note: Modifier XU or 59 may be appropriate, according to Moda Health, because the two procedures are separate procedures.

“This modifier [XU] would be used when the second procedure is usually part of the first, but for a medically relevant reason, it was done at a different time,” Hauptman adds.

Resource: Refer to Moda Health’s complete reimbursement policy at www.modahealth.com/pdfs/reimburse/RPM027.pdf.

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