Modifier Coding Alert

Modifier Guidance:

Look at Published X{ESPU} Examples Some Payers Are Offering, Part 2

Published on Thu Mar 19, 2015

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Making your distinct separate procedural coding more specific will strengthen your claims.

There is help out there for you while you wait for more clarification from CMS on when to use the X{EPSU} modifiers. Payers are publishing their instructions orproviding you with online direction.

Getting a glimpse at payers’ examples of when each modifier applies will helpyou submit successful claims. In this second part of our two-part series on the X modifiers, review guidance from three more payers to help you learn when to use each of the four new modifiers.

Review the X Modifier Background

You have been waiting for more instruction, since the CMS introduction of thefollowing four new modifiers on Aug. 15, 2014:

XE (Separate encounter)
XP (Separate practitioner)
XS (Separate structure)
XU (Unusual non-overlapping service).

While you wait, check to see if your payers have published their policies for using X{EPSU}.

“Having guidelines for these will certainly be helpful,” says Suzan (Berman)Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. “However, as the provider community starts to usethem, the payers will learn how the modifiers have been interpreted by the providers.They can then target the guidelines so that we all know how and when to use them.”

See Available Instruction

You know the purpose of modifier 59 (Distinct procedural services) is to identifyprocedures or services (other than E/M) that you normally do not report together.You also know that CMS and some private payers want you to use the newmodifiers when appropriate but they will still recognize 59. You will need to diginto each payer’s policy to know exactly when and how to use the four new Xmodifiers. Take a look at what some payers are telling you to do.

United Healthcare: UHC, a network that provides healthcare plans across thecountry, is following CMS by continuing to use modifier 59 when no other more descriptive modifier is available.

Instructions from UHC show you which of the four Xmodifiers you should use with certain types of billingsituations, as follows:

Anesthesia — XE, XU
Bilateral — XS
CCI editing — XE, XP, XS, XU
Laboratory services — XE, XP, XS, XU
Maximum frequency per day — XE, XS, XU
Obstetrical — XE, XS, XU
Pediatric and neonatal critical & intensive care
services — XE, XS, XU
Procedure to modifier — XE, XP, XS, XU
Professional-technical component — XE, XP, XS, XU
Radiology multiple imaging reduction — XE
Rebundling — XE, XP, XS, XU.

Resource: Refer to www.tinyurl.com/p35g87m fo rmore information about how UHC wants you to use the X{EPSU} modifiers.

Tufts Health Plan: Tufts Health Plan, a healthcare plan in Massachusetts and Rhode Island, published a policy similar to CMS’s. The guidance states that Tufts will continue to accept 59 or the new X modifiers for claims with dates of service on or after Jan. 1, 2015. The reimbursement for claims with one of the four X modifiers will be the same as if the practice had billed with modifier 59.

Resource: Refer to www.tinyurl.com/oyxawsn for more information.

Novitas: In its policy, Novitas, a Medicare Administrative Contractors (MAC) doing business in the southern and northeast parts of the country, provides examples from CMS with its own suggestions for the use of XE, XS, and XU only. They accept XP, but they don’t provide an example for XP. The examples are:

Use modifier XE when two procedures take place in separate encounters. For example, your physician performs a stress test (93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report) in the morning and an ECG (93040, Rhythm ECG, 1-3 leads; with interpretation and report) in the afternoon. You will attach XE to 93040.

You might use modifier XS when nail treat mentinvolves debridement of multiple nails and a corn on the same foot. The corn cannot be next to the debridement toenail. The claim will include 11055 (Paring or cutting of benign hyperkeratotic lesion [eg, corn or callus]; single lesion) and 11720 (Debridement of nail[s] by any method[s]; 1 to 5). Attach XS to 11720.

You’ll use modifier XU with procedures on the same date that do not normally take place on the same date. The surgery should involve different organs or anatomic regions, or different, non-contiguous lesions in different regions of the same organ. An example of two procedures might be 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses]; first lesion) and 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

Resource: Refer to www.tinyurl.com/nsrf56e for the complete policy.