Pain Management Coding Alert

Published on Thu Nov 03, 2016 PDF

Modifier 59 or one of the X modifiers? Choice still payer-dependent.

When deciding if the provider performed a pair of distinct procedural services, you used to be safe if you knew whether you could use modifier 59 (Distinct procedural service).

Caveat: Now, not only is the coder tasked with deciding whether a payer will consider a procedure “distinct”; now, she’s also got to check which type of distinct procedural service modifier the payer accepts.

The “X” Factor: Some payers will want you to use the newer, more specific X modifiers — while others will want you to continue applying modifier 59 to your distinct procedural services coding. Check out this expert insight on how to ace each modifier 59/X codingclaim.

Check With Payer on 59/X Question

Simply put, modifier 59/X applies “when two services that are usually bundled are not bundled for a specific defined reason,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC,  internal audit manager with PeaceHealth in Vancouver, Wash.

Modifier 59/X “lets payers know that even though these services are normally not billed separately from one another, in this case it is appropriate,” confirms Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.

For official guidance on which codes are eligible for modifier 59, check out the Correct Coding Initiative (CCI) edits, which Medicare publishes quarterly to update the code sets that you can separate with modifier 59/X. Learn more about CCI edits at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.

X factor: Medicare created the more specific X modifiers to replace the vaguer modifier 59 descriptor. The X modifiers are:

• XE: Separate encounter (A service that is distinct because the provider performs it during a separate encounter)
• XS: Separate structure (A service that is distinct because the provider performed it on a separate organ/structure)
• XP: Separate practitioner (A service that is distinct because a different practitioner performed it.)
• XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service)

Best bet: Check with your payers if you are uncertain about their stance on modifier 59/X. Some private payers might prefer that you still use the 59 modifier. Experts say that you should opt for modifier 59 unless you have specific guidance from a private payer — or a local coverage determination (LCD) or national coverage determination (NCD) for a Medicare payer.

“My recommendation would be to use modifier 59 for all payers unless instructed to do otherwise,” Bucknam says.

Bottom line: “There are some payers that recognize the X modifiers following Medicare, while others do not,” explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at Acusis, LLC, in Pittsburgh, Pa.

Unbundle Under This Quintet of Circumstances

As for when to use modifier 59/X, the main reasons you might be able to unbundle two bundled services are:

• The provider performed the service on a different part of the body. If the payer requires an X modifier in this instance, you’ll choose the XS modifier, Bucknam says.
• The provider performed the service during a different session. If the payer requires an X modifier in this instance, you would opt for the XE modifier, Bucknam confirms.
• The services, while occurring during the same encounter, involved separate practitioners. If the payer requires an X modifier in this instance, you would opt for the XP modifier.
• The provider performed two “timed” services during the same encounter, but provided those services sequentially. If the payer wants an X modifier, choose XU in this case, Bucknam confirms.
• A diagnostic procedure that is the basis for a therapeutic procedure during the same session. “There isn’t a great X modifier for this one,” Bucknam laments. If you are unsure of your payer’s modifier 59/X stance on these encounters, contact a rep before submitting the claim.