Modifier Coding Alert

Reader Questions:

XP Won't Override 0 Modifier Indicato

Published on Tue Jun 02, 2015

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Question: One of our physicians performed an E/M service along with same day psychotherapy (90837) performed by a psychiatrist from our same group practice. I am planning on using modifier XP with 90837 to separate the codes. Is this correct?

Illinois Subscriber

Answer: First you should note that, according to Correct Coding Initiative (CCI) edits, you will face bundling if you are trying to report an individual standalone psychotherapy code (such as 90837, Psychotherapy, 60 minutes with patient and/or family member) with an E/M code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient…) on the same claim. These edits carry the modifier indicator “0,” which means you cannot overcome the edit by using any modifier, even XP (Separate practitioner). So, if you file both the services on the same claim together and the payer is following CCI edits, the payer will deny the E/M code as this is the column 2 code in the edit set with individual psychotherapy codes.

These edits are generally consistent with Current Procedural Terminology (CPT®) guidelines, which instruct CPT® users to report an add-on code, such as +90838 (Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service [List separately in addition to the code for primary procedure]) when providing psychotherapy and an E/M service to the same patient on the same date. You mentioned that the physician and the psychiatrist are a part of the same group practice. Therefore, this may be the approach that you need to take if a single group identification number identifies both your clinicians.

Alternatively, if you typically report the physicians’ services separately using their individual national provider identifier (NPI) numbers, you can potentially report the E/M service on one claim under the rendering physician’s NPI and report 90837 on a separate claim using your psychiatrist’s NPI. To avoid a potential denial or support a subsequent appeal in this situation (since both your clinicians are in the same group) you may need to provide proper documentation to indicate that two different physicians from different specialties in the same group practice provided two different services to the same patient on the same calendar date of service. For Medicare, you can also point to Section 30.6.5 of Chapter 12 of the Medicare Claims Processing Manual, which states that “Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.” This should help the claims get paid.