Case Studies: Modifier 59 and X[ESPU] Use

Case Studies: Modifier 59 and X[ESPU] Use

When I last wrote “Modifier 59 – To Use or Not to Use”, I promised to follow it up with some real-life examples of when we should be using the 59 or the new Medicare X[ESPU] modifiers. Let’s look at some clinical examples and first determine if the 59 is applicable, and then assume it is a Medicare case and assign the appropriate “X” modifier in place of the 59 modifier.

Case 1:

Doctor performs a bilateral endoscopic balloon sinus dilation of the frontal sinuses and a left-sided endoscopic balloon sinus dilation of the sphenoid sinuses.

In this case, I am also addressing the new code combining the balloon sinus dilation (BSD) of the frontal sinus with the balloon sinus dilation of the sphenoid sinus when they are performed on the same side. This code, 31298, is described as Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation). This code would represent what was performed on the left side. But since the frontal sinuses on the right side also were dilated via BSD, we will need to also code 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) for the right-sided BSD. We have 31298 on the left and 31296 on the right. But since 31298 includes a frontal BSD, CCI bundles 31296 into 31298 should they be performed on the same side. But in this case, they were not performed on the same case. So, we would code using the 59 Modifier:

31298-LT

31296-59-RT

Modifier 59 is being used because the right sided BSD, 31296, is being performed on a separate structure, the right sinuses while the combination code, 31298 is being performed on the left side. That means that if this was a Medicare patient, we would use the XS instead of the 59 Modifier to tell Medicare that we are unbundling these two codes because they are being performed on separate structures.

31298-LT

31296-XS-RT

Modifier Case 2:

Patient has a colonoscopy with ablation of polyps, 45388 Colonoscopy, flexible with ablation of tumor(s), polyp(s) or other lesion(s), at 10 in the morning. She is brought into recovery after the completion of the colonoscopy at 10:15. She awakens and is being fed a snack when she notices blood on the sheet. She calls over the nurse who gets the gastroenterologist. It appears that she has started to hemorrhage. She is brought back into the endoscopy suite at 11:45 am and the gastroenterologist re-inserts to scope to see what is going on and sees that a blood vessel has popped and needs cauterization to control the bleed. He cauterizes the vessel and the bleeding is brought under control.

Control of hemorrhage, 45385 Colonoscopy, flexible, with control of bleeding, any method,  is considered integral and part of a colonoscopy procedure. But this hemorrhage started after the procedure was completed and the patient was in recovery. Since the patient was then brought to the endoscopy suite a second time for the control of the hemorrhage, this is considered a different encounter.

45388

45382-59

Since this was a second encounter, if this was a Medicare patient, the modifier which would replace modifier 59 would be XE to represent separate encounter.

45388

45382-XE

Modifier Case 3:

A patient presents to the emergency department with multiple lacerations from a motor vehicle accident. The emergency department physician performs an intermediate repair of a 2.5 cm laceration on the right arm and then calls a general surgeon for a consult for a more extensive laceration on the left leg. The surgeon performs an intermediate repair of a 7 cm laceration on the left leg. These two services would be coded and billed out with a modifier 59  or a modifier XP,  if the patient is covered by Part B Medicare.

12032

12031-59 or XP for a Medicare Part B patient

Modifier Case 4:

A lot of the examples of the use of the modifier XU  on Medicare carrier websites appear to really be situations where  modifier XS  would be more applicable because of separate structures or separate sites. The modifier XU  should only be used if one of the other X modifiers do not apply.

For example, a patient presents to the ER with sudden onset of angina. The patient is taken to the catheter lab where a diagnostic heart catheter of the coronary arteries is performed and reveals occlusion of the LAD. Based on the results of the diagnostic catheter, a decision is made to percutaneously insert a stent in the LAD. The modifier 59  would be used, or modifier XU if the patient is a Medicare Part B beneficiary

92928

93454-59 or XU for Medicare Part B patient.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

About Has 25 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

6 Responses to “Case Studies: Modifier 59 and X[ESPU] Use”

  1. Heather says:

    For case 2 You have the control bleeding in your example as 45385 which it should be the 45382 that you have below with the breakdown.

  2. Sathish says:

    Which is much useful. Thanks for sending

  3. Mindy Langman says:

    For the first case study the modifiers 59 and XS are not applicable. The NCCI states that the “Modifier 59 shall only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.” AND “The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.” Since the modifiers RT and LT already indicate the procedures were done at different anatomic sites, the use of 59 or XS is redundant.

    I am also wondering about the use of the modifier 78 for Case 2. Again the NCCI states: “Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.” Since the patient was returned to the endoscopy suite on the same day of the procedure wouldn’t the modifier 78 apply in this case?

  4. Donna says:

    Are the x modifiers required to be used? Last I heard they were available but not a requirement.

  5. Barbara J. Cobuzzi says:

    Mindy,

    LT and RT are HCPCS modifiers and not CPT Level 1 modifiers. Not all payer process for payment when they are used. I can tell you, from experience, that even Medicare carriers do not break the bundles for LT and RT often. Experience has shown that the LT and RT modifiers are more informational in payer adjudication systems than modifiers that affect bundling rules.

    As for the second example, the global for which you would use the 78 modifier does not start until the day after the surgery. The control of hemorrhage submitted with the same date as the colonoscopy appears as if it took place during the procedure. If it did take place during the procedure, it would not be payable. BUT since it took place after the procedure, it is payable and the 59 modifier applies to show a second encounter. If this was a Medicare Part B patient the XE would be used.

  6. Barbara J. Cobuzzi says:

    Donna,

    The X[ESPU] modifiers are not required to me used. But if I worked for a Part B carrier and I saw a provider not using the X modifiers and using 59 modifiers, I would want to audit those records to make sure that the 59 was being used correctly.

    Why not use the X[ESPU] modifiers if it provides your Part B carrier more information where it comes to the reason for the unbundling exception?

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