Modifier Coding Alert

Published on Fri Jan 23, 2015 PDF

The future may bring clinical situations that require an “X” modifier.

Medicare hasn’t offered you any further instructions for the new X{EPSU} modifiers, even though January 1 has come and gone and you need to start using them. The good news is that coding experts are starting to suggest how they think you should use these new additions in different specialties. 

Take a look at pathology/laboratory and how experts expect X{EPSU} will fit into that specialty so you start applying the advice to your own specialty. 

Lean Toward New Separate Services Modifiers

CMS introduced the four new modifiers on Aug. 15, 2014, in order to hopefully alleviate modifier 59 (Distinct procedural service) errors. CMS describes the incorrect and most common use of 59 as the “modifier to use to bypass National Correct Coding Initiative (NCCI).” 

The purpose of modifier 59 is to identify procedures/services, other than E/M, that you don’t normally report together, but are appropriate under certain circumstances. With more precise modifier options, CMS believes they will see fewer modifier 59 use errors. 

Pointer: CMS is strongly asking providers to use the new modifiers (X[EPSU]) instead of modifier 59 as of Jan. 5, 2015 but they aren’t requiring their use. CMS is hoping for a “rapid migration” to the following four new modifiers:

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

“I think the reason we haven’t heard anything more out of CMS is the fact that what they thought was clear (from the original transmittal) was not clear at all to the rest of the industry,” says Joan Gilhooly, MBA, CPC, CPCO, president and consultant for Medical Business Resources, LLC in Lebanon, Ohio. “I suspect that they’re doing some regrouping to come out with more clear guidance.”

Once CMS provides more information about the pointed modifiers, you will better understand their full and intent and purpose.

“It remains to be seen whether this added measure of transparency will actually facilitate MAC claim processing and reduce denials or requests for extra information prior to claim adjudication,” says Dennis Padget, MBA, CPA, FHFMA, lead consultant at PathConsulting in Laguna Beach, Calif. “Deciding which of the alpha ‘separate procedure’ modifiers fits a particular situation will take a while to get used to, but we’ll overcome the transition fairly quickly I hope. But I still have to wonder about the practical benefit this change will ultimately have for MACs and providers.”

Remember: Medicare is not saying they won’t accept modifier 59 but if any of the four new modifiers fits your situation better, then you are to use those, says Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J.

“While CMS will continue to recognize modifier 59 in many instances, it may selectively require a more specific X{EPSU} modifier for billing certain codes at high risk for incorrect billing,” adds Jandroep.

Here are some specialty-specific pathology/laboratory examples for some of the possible uses of the new CPT® separate service modifiers.

Look to XE For Multiple Encounters on Same Date

When you have a patient come to the office in the morning for a procedure or service and then later the same day they come in again for an unrelated procedure, you will use modifier XE.

Example: Your pathologist performs an IHC stain in-house to complete an outside consult case. Report 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) and 88323 (88323, Consultation and report on referred material requiring preparation of slides). Attach XE to 88342 since the services took place during multiple encounters.

Use Modifier XP with Multiple Physicians on Same Date

You’ll turn to modifier XP when you are reporting two services for the same patient on the same date of service, if more than one of your physicians from the same specialty renders the service and they bill using the same tax ID. The patient may or may not see your physicians during the same encounter. 

“Different physician modifier XP in pathology billing will come into play only in limited circumstances. If all charges are billed on the claim under the NPI of one primary pathologist (the one who signs out the case), then XP won’t apply at all as best we can judge at this point,” explains Padget. If your claim has different pathologist NPIs, attaching XP will explain why the same CPT® code appears multiple times on the claim.

Rely on XS for Procedures on Separate Structures

On the same date of service for the same patient, one of your physician’s performs multiple procedures on separate structures, organs, or anatomical sites. Modifier XS the best modifier choice for you to use with the service.

Example: A pathologist examines one specimen intra-operatively by touch prep (88333, Pathology consultation during surgery; cytologic examination [eg, touch prep, squash prep], initial site) and she examines a separate specimen intra-operatively by frozen section (88331, Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen). Report 88333 and 88331, attaching XS to 88333 to communicate that the service was on a separate structure. 

Attach XU for Services That Don’t Overlap

When a physician performs a service on a patient that is distinct because it doesn’t overlap usual components of the main service, you use modifier XU. The multiple procedures or services have to be on the same structure, organ, or anatomical site in order to use modifier XU.

Example: You code 88342 (Immunohistochemistry or immunocytochemistry,per specimen; initial single antibody stain procedure) when your physician performs immunohistochemistry (IHC) the same day as a flow cytometry (88184-88189, Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; …) for a bone marrow case as long as IHC is not usual component of flow. Report 88342 and a flow cytometry code from the 88184-88189 range. Attach XU to the first of the services making it clear that the services don’t overlap.