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Use of X Modifiers in Gastro

Selina Posted Wed 11th of March, 2020 14:01:01 PM
Hello, We are having an issues with Aetna denials for modifier 59 and are wondering if the X modifiers are acceptable to use in GI? For example could XS be used with multiple endo procedures instead of a 59 (45385 and 45380)? Or XU?
SuperCoder Answered Thu 12th of March, 2020 07:07:15 AM



Thanks for your question.



Please let us know the reason for denial so that we can provide you the best response. Modifier XS is applicable when A service that is distinct because it was performed on a separate organ/structure and modifier XU Unusual non-overlapping service is applicable when a service that is distinct because it does not overlap usual components of the main service. In the above-stated scenario Modifier, XS is not applicable as both the procedures performed on the colon/same organ. Modifier XU can be used to override the edit. Please check with your payer for any specific guidelines for the use of modifier 59/XU.



Hope that Helps!

Selina Posted Thu 12th of March, 2020 10:33:40 AM
Hi - the Aetna denials state: CO 97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. N19 - Procedure code incidental to primary procedure.
SuperCoder Answered Fri 13th of March, 2020 04:37:12 AM

Thank you for your Question!


As per NCCI manual 2020, The NCCI PTP edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by using modifier 59 or -X{EPSU}. The use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions.

Incidental is defined as a procedure carried out at the same time as a primary procedure but is not clinically integral to the performance of the primary procedure and therefore, should not be reimbursed separately. Hence, try to check for the CPT codes with the detailed operative report. If separate documentation is provided for removal of polyp and biopsy procedure on different locations on colon then you can appeal again with these codes along with a detailed operative note and if both procedures are performed on the same location then biopsy procedure code would be inclusive to a major procedure.

Kindly check with your payer for more specific guidelines.


Hope that Helps!

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