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Key Modifiers used instead of Modifier 59

Posted By ECLAT Heath Solutions

The “X” modifiers were effective for Medicare billing January 5, 2015 as a subset, and to be used in place of modifier -59, Distinct Procedure.

There are four “X” modifiers that can be used, if appropriate:

XE - Separate Encounter
XS - Separate Structure
XP - Separate Practitioner
XU - Unusual Non-Overlapping Service

While they have not been mandatory to use according to CMS, when released, providers were encouraged to use them in place of modifier 59 as they provide more specific information as to why an NCCI edit should be bypassed.

Let's walk through some "X" Modifiers below to differentiate which is the most suitable.

XE Modifier - Separate Encounter

The NCCI contains many edits bundling standard preparation, monitoring, and procedural services into anesthesia CPT codes. Although some of these services may never be reported on the same date of service as an anesthesia service, many of these services could be provided at a separate patient encounter unrelated to the anesthesia service on the same date of service. Providers may utilize modifier 59 or XE to bypass the edits under these circumstances.

XS Modifier - Separate Structure

Example: A biopsy performed at the time of another more extensive procedure
(e.g., excision, destruction, removal) is separately reportable under specific circumstances.

If the biopsy is performed on a separate lesion, it is to be separately reported. This situation may be reported with anatomic modifiers or modifier 59 or XS. Modifier 59 or XS is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

If multiple lesions are removed separately, it may be appropriate (depending upon the code descriptors) for the procedures to report multiple HCPCS/CPT codes using anatomic modifiers or modifier 59 or XS to indicate different sites or lesions.

CMS payment policy does not allow separate payment for CPT codes 63042 (Laminotomy...; lumbar) or 63047 (Laminectomy...; lumbar) with CPT codes 22630 or 22633 (Arthrodesis; lumbar) when performed at the same interspace. If the two procedures are performed at different interspaces, the two codes of an edit pair may be reported with modifier 59 or XS. However, if the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, CPT code 22830 may be reported separately with modifier 59 or XS.

The CPT code descriptor for some genitourinary procedures includes a hernia repair. A HCPCS/CPT code for a hernia repair is not separately reportable unless the hernia repair is performed at a different site through a separate incision. In the latter case, the hernia repair may be reported with modifier 59 or XS.

CPT codes 76376 and 76377 (3D rendering) are not separately reportable for nuclear medicine procedures (CPT codes 78012-78999). However, CPT code 76376 or 76377 may be separately reported with modifier 59 or XS on the same date of service as a nuclear medicine procedure if the 3D rendering procedure is performed in association with a third procedure (other than nuclear medicine) for which 3D rendering is appropriately
reported.

XU Modifier - Unusual Non-Overlapping Service

If an epidural or peripheral nerve block injection (62320-62327 or 64450-64530 as identified above) for postoperative pain management is reported separately on the same date of service as an anesthesia 0XXXX code, modifier 59 or XU may be appended to the epidural or peripheral nerve block injection code (62320-62327 or 64450-64530 as identified above) to indicate that it was administered for postoperative pain management.

Peripheral vascular bypass CPT codes describe bypass procedures with venous and other grafting materials (CPT codes 35501-35683). These procedures are mutually exclusive since only one type of bypass procedure may be performed at a site of obstruction. If multiple sites of obstruction are treated with different types of bypass procedures at the same patient encounter, multiple bypass procedure codes may be reported with anatomic modifiers or modifier 59 or XU.

For example, if one battery/generator is replaced (e.g., right side) and another is removed (e.g., left side), CPT codes for the “insertion or replacement” and “revision or removal” could be reported together with modifier 59 or XU.

Screening and diagnostic mammography are normally not performed on the same date of service. However when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography HCPCS/CPT code be reported with modifier GG (Performance and Payment of a Screening and Diagnostic Mammogram on the Same Patient, Same Day) and the screening mammography HCPCS/CPT code be reported with modifier 59 or XU.

For the unusual patient who requires two different types of pharmacologic stress tests (e.g., myocardial perfusion and echocardiography) on the same date of service, the amount of drug used for each stress test should be reported on separate lines of a claim with modifier 59 or XU appended to the code on one of the claim lines.

Transesophageal echocardiography (TEE) monitoring (CPT code 93318) without probe placement is not separately reportable by a physician performing critical care E&M services. However, if a physician places a transesophageal probe to be used for TEE monitoring on the same date of service that the physician performs critical care E&M services, CPT code
93318 may be reported with modifier 59 or XU.

A cardiac catheterization procedure or a percutaneous coronary artery interventional procedure may require ECG tracings to assess chest pain during the procedure. These ECG tracings are not separately reportable. Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59 or XU.


References:

  1. Coding Clinic for HCPCS - First Quarter 2015 Page: 1,2
  2. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1418.pdf
  3. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

Tags: Medical Coding, Medical Billing, CPT Codes