Specific Modifiers for Distinct Procedural Services

Specific Modifiers for Distinct Procedural Services

By Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CPCO

There have been quite a few blogs and articles lately addressing Medicare’s new -X{EPSU} modifiers to describe subsets of the 59 modifier for “distinct procedural service” via Transmittal 1422 Change Request 8863, dated August 15, 2014, effective on January 1, 2015. They go into detail describing the definitions of each X modifier, but they have not given examples. I thought I would use this as an opportunity to provide some examples of how we would use each of the X modifiers.

The 59 modifier covers multiple situations when a “distinct procedural service” may take place. From the AMA CPT® description of the modifier:

Documentation must support a:

  • Different session;
  • Different procedure or surgery;
  • Different site or organ system;
  • Separate incision/excision;
  • Separate lesion; or
  • Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual

Medicare’s Take on X{EPSU}

The MedLearn Matters (MLN) article (MM8863) on these new HCPCS Level II modifiers break down the correct usage of the 59 modifier and more align to the situations in which the 59 is used.

They indicate that the 59 modifier should only be used in the following three circumstances:

• Different encounters
• Different anatomic sites
• Distinct services

Interestingly, the MLN article indicates specific guidelines that the 59 modifier should be used:

• Infrequently (and usually correctly) used to identify a separate encounter
• Less commonly (and less correctly) used to define separate anatomic sites
• More commonly (and frequently incorrectly) used to define a distinct service

Medicare is concerned that the 59 modifier is not necessarily being used at the proper times and that the documentation is not present to support its use. As I have taught, the 59 modifier is the “Prednisone of modifiers”. It is very powerful and when appropriate, it can get us paid for both procedures when they are normally bundled, but under these special circumstances as outlined above in the bullets, they should not be bundled this time. But like Prednisone, which also can be a very toxic drug, use of the 59 modifier when the documentation does not support its use, when one of the above situations do not exist, just to get paid for two bundled procedures, it is very dangerous and non-compliant.

Medicare is concerned about allowing bundled pairs to be bypassed with the 59 modifier and the potential for abuse. By adding these four more specific HCPCS Level II modifiers, Medicare is getting additional information as to what special circumstances existed to justify the unbundling.

Medicare took the above six possible reasons to unbundle two bundled codes and broke them into four categories. They include the following:

• XE (Separate encounter) – this applies to the “different session” or possibly “different procedure or surgery” in the 59 modifier description
• XS (Separate structure) – this includes the “separate incision/excision”, “different lesion”, and “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description
• XP (Separate practitioner) – this can include a possibly “different procedure or surgery”, “different session”, or “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description. Key to this modifier is that a different surgeon in the practice (same group NPI) performs the second procedure.
• XU (Unusual non-overlapping service) – The use of a service that is distinct because it does not overlap usual components of the main service) – “different procedure or surgery”, “different session”, or “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description. Key to this modifier is that the two procedures are rarely performed together.

Application of X{EPSU}

So, let’s look at some examples of specific situations when the new -X{EPSU}modifiers might be used:

• XE (Separate encounter) – The physician performs a diagnostic nasal endoscopy at 10 a.m. (31231) The patient goes to the ER at 8 p.m. that evening with severe epistaxis, so the doctor uses complex techniques to control the anterior epistaxis (30903). The diagnostic endoscopy is bundled with the control of epistaxis if they were done during the same encounter. Since they were done at different encounters, the XE would be used with the 30903 because it is the column 2 code.

Another example of a separate encounter would occur when we have a patient who has a post-operative bleed. Control of hemorrhages are considered inclusive to most surgeries. But when the patient is closed and brought to recovery, goes home, or to their inpatient room and then a post-operative bleed is detected causing them to return to the OR to control the hemorrhage will require a 59 modifier today. For Medicare, the XE modifier will be applied to the post op bleed control code which took place during a separate operative session.

• XS (Separate structure) – Two codes that often get unbundled inappropriately are bone marrow aspiration, 38220 and bone marrow biopsy, 38221. They are not permitted to be coded together unless they are performed at different sites. So, if the physician performs a marrow biopsy on the left hip and has documented medical necessity to perform a bone marrow aspiration on the right hip, both procedures can be coded and billed and as of January 1st, 2015, the XS should be applied. You have to make sure that the separate sites are not just used in order to get the doctor paid for both procedures and that there is medical necessity documented for performing both procedures and using two separate sites in order to use either a 59 modifier or with CMS the XS modifier. The 30220 would get the XS modifier since it is the column 2 code.

Another example of the XS modifier can be found in my favorite specialty, Otolaryngology. The surgeon often performs one procedure in the left sinuses and a bundled service (component code) in the right sinuses (or visa versa). The only way to get paid for these two bundled codes performed on the left and right is to use the 59 modifier. Now, for a Medicare patient, as of January 1st, we would use the XS modifier. For example, if an endoscopic total ethmoidectomy (31255) is performed on the left and only an endoscopic partial ethmoidectomy (31254) is performed on the right side, both these bundled codes can be coded, with the XS going on the 31254, the column 2 code.

• XP (Separate practitioner) – Unlike separate encounter and separate structure, this alternative would be used much more infrequently. This modifier is used when one doctor in the group does a service and another practitioner in the practice does another service that’s bundled with the first. There has to be medical necessity documented for using the two different practitioners for these two bundled procedures. I believe you might see this in the care of trauma patients, when multiple physicians care for the patient at the same time.

• XU (Unusual non-overlapping service) – Sometimes CPR is done while the patient is under anesthesia because the patient is not emerging from anesthesia. The anesthesiologist may have to resuscitate the patient using CPR. This is part of anesthesia services. In this case, the anesthesia services and CPR are bundled. But if CPR is performed as an emergency procedure because the patient codes, it is separately coded and billable for the anesthesiologist. Instead of using a 59 modifier with the 92950 and 92953 as we currently apply, an XU modifier would be used as of January 1st.

Most situations fall under XE and XS definitions since most situations when a provider reports a distinct service is when a separate encounter or separate site is involved. The other two,  XP and XU would be rarely used because these situations occur rarely in medical practices. Of course, the type of practice you have and types of procedures and services your physicians perform will influence the frequency of utilization. Use of the 59 modifier and ultimately for Medicare, the -X{EPSU} could be cause for a red flag to be raised if the frequency is high, in particular, higher than your peers. That will be reason for audit requests. Make sure your documentation supports the utilization of any modifier indicating a “distinct service” so that you can pass any audit with flying colors.

By the way, Medicare does say that you can keep using the 59 modifier, but I believe that they will use that as a reason to also red flag a practice. They are requesting voluntary compliance with the -X{EPSU} modifiers in order to track utilization and it will not look very good if your practice is not willing to comply with this request, in my opinion.

Resources: To read the transmittal and MLN Matter article, go to the CMS website.


4 Responses to “Specific Modifiers for Distinct Procedural Services”

  1. cindy s. says:

    can 59 be used with XU but on different lines

  2. Barbara Cobuzzi says:

    Cindy S. No, you would use only one. For Part B Medicare, I recommend sticking with the X modifiers if you can. So if XU applies use that. If you cannot find a X{EPSU} appliable to the second line, there is a good chance that the 59 modifier does not apply, as th X{EPSU} covers all instances when 59 would be applicable.

    if the payer is not Part B Medicare, I would stick with the 59 modfier unless that payer has issued information that they are also using the X{EPSU} modifiers.

    I hope that this helps.

    Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO

  3. Candice Ruffing, CPC CPMA CPB CENTC says:

    Great Blog Barbara!!

  4. Sharon Stouder says:

    Would these same parameters apply to a facility (freestanding ASC), specifically for GI procedures, or would the 59 be more applicable?

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