Modifier 59 New Additions | Physician Practice Manager Course – Video

Laureen:   Alright, so our first question, we’re going to open up the line for Jo-Anne, she is one of our instructors and she’s recently increased her time with us, we’re very excited. Jo-Anne, can you hear us? Or can we hear you?

Jo-Anne: Yes, I can. Can you hear me?

Laureen: We can. And if you can hit your little camera button, so that we can see your lovely face.

There you go!

Alicia: There she is.

Laureen: So, can you see your slide, to go ahead and…?

Jo-Anne: Oh yes, OK.

Laureen: OK. You can talk a little bit about yourself, Jo-Anne. I think you came on the webinar once or twice before. You might want to tell the group what courses you teach for CCO?

Jo-Anne: Oh, OK. I teach the coding course, the Physician Practice Manager Course and the ICD-10 Mini Course. So, very involved with that, and the students are great and I think the curriculum is wonderful, so I’m thrilled to be here doing these with you guys.

Laureen: And Jo-Anne’s background, she is being very modest, she’s own and run a very successful billing company that her daughter is now taking over the reins, but she knows a lot about the reimbursement side of this business. So, the Physician Practice Manager Course, we’re very excited to have her in there and improving it with all of her great real world experience.

Jo-Anne: Oh, thank you.

Laureen: So, this question came from a student that – and Jo-Anne had done a blog article on this, I thought this would be a good one for her to go ahead and answer; so take it away Jo-Anne.

Jo-Anne: Modifier 59 Meets XE, XP, XS, XU

Q: I received a notice from AAPC stating that CMS is establishing the following new modifiers (referred to collectively as-X {EPSU} modifiers) to define specific subsets of the 59 modifier.

A: In basic English, picture modifier 59 as an umbrella and the 4 new X modifiers, the HCPCS modifiers, they’re just more selective. Medicare has spent a lot of money overpaying for the misuse of modifier 59, so this is an opportunity for Medicare to have the coders use very specific modifiers to explain the claim form and I like it. It’s just my only concern right now is that Medicare has not come forward with any specific example of how to use these codes. I have talked to other consultants and spoke with Medicare directly because I offered some examples and I just wanted to be sure that we were on the same page but I strongly recommend anyone that’s involved with using these modifiers to monitor with their billing company and see how they are being reimbursed.

Medicare wants you to use these X modifiers and the implementation date is January 5^th and also I know modifier 59 is still available but they will have the option to deny your claim if they feel that one of this X modifiers is better for the claim form. And also, if you’re confused, do not put modifier 59 and one of these X modifiers on the same line because that’s a guarantee denial; so that’s just a little heads up.

The four modifiers that are very selective, that make up the modifier 59 is XE, which is a Separate Encounter, and that’s the service that is distinct because it occurred during a separate encounter on the same day. XS is a Separate Structure, a service that is distinct because it was performed on a separate organ/structure. Believe it or not, this one is not used correctly a lot of the time where the one above the separate encounter, it’s not used often, but they are pretty accurate when any coders use it. XP – Separate Practitioner is exactly what it is, a service that is distinct because it was performed by a different practitioner on the same day. The last one is very confusing, XU Unusual Non-Overlapping Service. It’s basically, I’ll have to show you the example because just the description of it is not even easy to understand: “the use of a service that is distinct because it does not overlap usual components of the main service.”

What does that mean? In all honesty, every consultant that I looked at their work, their interpretation was close, but not exact, and I came up with the scenario and ran it by Medicare, I’m in the Massachusetts jurisdiction and they said it was fine, but I go by the rule 2 out of 3 and I only asked once. No, I’m just waiting for them to give us examples, but the implementation date is January 5th.

The first coding scenario was XE-Separate Encounter, these are more visual so you can get an idea how it would work: A patient has an annual gynecological exam with PAP, pelvic & breast exam, UA, & EKG at 8:00 a.m. She also wanted the Mirena IUD inserted at the time of her visit but the IUD was not in the office, it was en route; so the doctor said “Come back later when I know it’s here and we’ll insert it for you.”

In this case where it is a separate encounter, you would actually bill the basic gynecological exam in all of those procedures but then you would append modifier XE to the 58300 – insertion of IUD. And that would indicate that the patient came back at a later time to have the service performed on the same date.

Laureen:   And that’s instead of using 59.

Jo-Anne:             Instead of 59.

Modifier 59 New Additions | Physician Practice Manager Course – Video

Laureen: It’s supposed to be a more specific 59, so Medicare is really trying to drill down and get us to tell them of all the different ways you could use 59, what’s your way that you’re trying to use in this scenario.

Jo-Anne:           Absolutely. They’re very selective now, and if there’s any way at all, if a coder is confused and uses 59, it really is up to Medicare whether they will accept it or not, but they are definitely pushing for these X modifiers and just to make sure that Medicare

Advantage plans also will be using it and keep an eye open to local carriers because they seem to adapt to a lot of the Medicare…

The XS- Separate Structure – Believe it or not, I never would think that this is something that coders have a problem with, but a lot of coders don’t have a clinical background, they’ve kind of evolved into it. Some haven’t even studied for their CPC yet, there are a lot of problems with this.

This example, I hope it’s easy enough for people to understand: The patient has 5 benign lesions removed on his left lower limb by cryosurgery. CPT code would be 17110. He also has laser surgery performed on a premalignant lesion on his left upper limb and that CPT is 17000. These are called mutually exclusive procedures and normally the CPT code 17000 is a column 2 code for 17110. However, lesions were located on the upper and lower limb so modifier XS would be appended to the column 2 code 17000. Then, I gave the example of how you would use 17110 first and then 17000-XS as second.

Laureen:     The 17000 would normally be considered bundled into the 17110.

Jo-Anne:       Exactly.

Laureen:     So, in order to tell the story, like, hey I know you think this is on the same side or in the same area, but it’s not. And we would normally use a 59 to tell that story, now we have to use an XS.

Jo-Anne:       Exactly.

Laureen:     OK.

Jo-Anne:       Honestly, I know when you take the CPC exam, you may have something like this thrown at you…

Laureen:           I doubt it.

Alicia: Yeah.

Laureen:         Or not yet.

Jo-Anne:       I code everything and then I go to my SuperCoder.com and I look to see because they will in fact tell you when you can and cannot add modifier and that’s where abuse comes in because some coders and doctors think, “Well, gee, if I add modifier 59…” or say in this case XS, “I’ll get paid.” But if it’s not documented Laureen:       That’s why we’re in this… some background on this and it was like billions of dollars that 59 has cost, so that’s where they’re targeting this.

Jo-Anne:       Exactly. Now, the XP-Separate Practitioner, that’s pretty straightforward. As an example:

The patient is seen for an upper respiratory infection. While he is being examined by Dr. #1, he mentions he has a lump under his hairline that has bothered him for 2 months. He asks the doctor to look at it because the patient himself could not get a good visual. When the doctor looked at it, it was definitely suspicious so he asks Dr. #2, a dermatologist in the group to look at the patient. Dr. #2 performs a biopsy of the skin immediately.

In this case, two practitioners in the group, and the first one would bill for the treatment of the upper respiratory infection. Maybe he did a rapid strep test, whatever. Dr. #2 would be billing for biopsy of the skin, single lesion – that’s a consolidated description, by the way, of the 11100. But it’s basically, the second doctor would be appending XP to the biopsy of the skin, so that’s just indicating.

I also know on the claim form, doctors, different providers, their individual MPIs would also link to the procedures and services provided, but in this case, [? 0:24:28] focusing on the modifier, so Dr. #2 would be billing for the biopsy and adding the XP.

The last one, which is a little bit confusing, XU- Unusual Non-Overlapping Service: A patient had an abnormal chest x-ray and has not had a definitive diagnosis made. He was scheduled strictly for a diagnostic bronchoscopy. During the bronchoscopy, 31622,the surgeon discovers that the patient has extensive lung cancer and decides the patient needs surgery immediately. The surgeon gets consent from the patient and proceeds at that point with an open lobectomy (surgical removal of the lobe in the lung, 32480).

Typically, a bronchoscopy would be considered part of the lobectomy and not billed. (If the patient had an established diagnosis, a lot of times doctors will use a bronchoscopy just to check out the situation before cutting a patient open). But in this case, that was not the case, the bronchoscopy was done to see what was going on and found the cancer. And so, according to the Correct Coding Initiative, in this case, you would append modifier XU (or in the old days, 59) to the bronchoscopy because it was through that bronchoscopy that the diagnosis of lung cancer was established, so making the doctor proceed with the open lobectomy.

So you would bill the lobectomy and then the Correct Coding Initiative would tell you to append modifier 59 and now it will be January XU to the bronchoscopy. But if there’s already a definite diagnosis code linked to it and the doctor happens to do a bronchoscopy, it’s considered a separate procedure unless it’s a case like this year and you would not bill for the bronchoscopy. I don’t know if that’s clear enough, but basically that’s what that is.

Laureen:     Yeah, that’s the one too that I think is the most under suspicion, is the need for people to use the MU. They want to really make sure if there’s overlapping services that that’s been taken into consideration because…

Alicia:         I can see statistically why it makes a difference to code it that way versus another way.

Jo-Anne:       Yeah. It can get confusing.

Laureen:         I did want to draw everyone’s attention to – there is a forum post as well as an article by Jo-Anne on the topic. If you go to our discussion board and you click in the Medical Coding & Reimbursement discussion field, this is in there. This is free, it’s not just for the Replay Club customers; so go ahead and take advantage of that. It’s kind of like the transmittal that kicked it all off, it came out in the summer. MLN Matters is a CMS’s way of explaining stuff to us in little more broken tongue language. Here’s their Modifier 59 article by article by CMS, here’s Jo-Anne’s article, AAPC wrote an article. And then, this is an old one but it historically showed why this started to happen, 2005 article from the OIG. That one I thought was actually very interesting because it showed how much money were talking about being lost here.

If you read those documents, I think you’ll get a much better feel for how to use those new modifiers. Just picture that you’re on CMS’s side and lots of money has been given out because 59 makes things go through like butter and get paid.

Jo-Anne:     Absolutely.

Laureen:       They’re making you, they’re putting the onus on you, the coder, and the physician signing off on it, that we’ve been thoughtful about what circumstance we’re coding for. And remember, 59, is the modifier of last resort. So now, with this four new modifiers, we have to use one of them if they apply, even though Medicare is saying they are currently still accepting 59, it’s still the modifier of last resort. So we have to use any other modifier to tell the story, if one is available.

Hopefully, keep that in mind; read the resources here and then my key takeaways are pretty much what Jo-Anne said. So, good job, I know this has been one we’ve been getting peppered with questions lately. I said, “I promise, we’re going to cover it on this month’s webinar.”

Jo-Anne:     But I will write a blog as soon as I find anything from Medicare, I will write a blog and site the examples that Medicare has given for clarification because I know that –

Laureen:         That will be great.

Jo-Anne:       Yeah. Because different parts of the country use different contractors and I know from experience, Massachusetts went from NHIC to NGS and they are night and day; so you really have to pay attention to your particular contractor.

Alicia: That’s a good point.

Jo-Anne:       But I will post it.

Laureen:   Thanks Jo-Anne, good job. Nice having a new face.

Jo-Anne:       You’re welcome. Thank you

Read More Related Information about Modifier 59

Medical Coding Use of Modifier 59 – Video

AAPC – Medicare Modifier