Pathology/Lab Coding Alert

Note NCCI Policy Manual updates.

Maybe your pathology practice has received a payer notice regarding the use of modifier 59 (Distinct procedure service) or one of the X{EPSU} modifiers.

If so, your lab may not be alone. Read on for a refresher on how and when to use these modifiers for lab and pathology services, and for highlights of National Correct Coding Initiative (NCCI) 2020 Policy Manual changes that shed some light on the subject.

Recall 59 and X{EPSU} Basics

Frequent modifier 59 misuse propelled CMS in 2015 to create the following four new, more-precise modifier options, known as the “X{EPSU}” modifiers, for reporting distinct service claims:

• XE (Separate encounter…) describes a service that is distinct because it occurred during a different patient encounter.
• XP (Separate practitioner…) describes a service that is distinct because it was performed by a different healthcare provider.
• XS (Separate structure…) describes a service that is distinct because it was performed on a different anatomic site.
• XU (Unusual non-overlapping service…) describes a service that is distinct because it does not overlap with the usual components of the main service.

Avoid: You should never use 59 and one of the X{EPSU} modifiers together for the same claim, because they’re redundant. The X{EPSU} modifiers describe a specific subset of circumstances that would warrant using modifier 59.

Always: CPT^® instruction states that “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

NCCI relationship: The NCCI procedure-to-procedure (PTP) edits list code pairs of medical procedures that are “bundled” and would not normally be provided together for various reasons, such as one service is included in the other, or the services are mutually exclusive. When providers document special “distinct procedure” circumstances, CMS allows providers to override a PTP edit pair and bill both codes together by using the appropriate modifier, such as 59 or X{EPSU}.

Payer differences: As a provider, you might find that your specific Medicare Administrative Contractor (MAC) and other payers might have varying rules about using modifiers 59 and X{EPSU}. You’ll need to keep track of those rules and bill accordingly to facilitate claims processing for different payers.

Check Out NCCI 2020 Manual for Specific Lab Direction

Although CMS initially stated the intention to phase out modifier 59 and encouraged providers to migrate to using the more selective modifiers, CMS still accepts modifier 59.

Update: The 2020 NCCI Policy Manual makes a move toward encouraging labs to use the more specific modifiers. By adding one of the X{EPSU} to the following examples (underlined added in 2020), CMS sheds light on how and when to use the modifier 59 alternatives:

• Chapter 10 Section L:1. “For a single specimen, only one code from a group of related codes describing a group of services that could be performed on the specimen with the same end result (e.g., 88104-88112, 88142-88143, 88150-88153, 88164-88167, etc.) shall be reported.” But if the different cytopathology preparation methods are for separate specimens from different anatomic sites, “modifier 59 or XS may be used to indicate that different levels of service were provided for different specimens from different anatomic sites.”
• Chapter 10 Section L:3. Medicare holds that one of the methods “immunocytochemistry (e.g., CPT^® codes 88342, +88341, 88344, 88360, 88361) and flow cytometry (e.g., CPT^® codes 88184-88189)” should establish the diagnosis, so you should not report codes from both families together. However, if “the initial method does not explain all the light microscopic findings… the physician may report both methods using modifier 59 or XU and document the need for both methods in the medical record.”
• Chapter 10 Section M:17. “Infectious agents may be identified by antigen detection (e.g., CPT^® codes 87301-87450), immunofluo­rescence microscopy (e.g., CPT^® codes 87260-87299), or nucleic acid probe (e.g., CPT^® codes 87471-87501, 87510-87592, 87640-87799) techniques. If a single test procedure produces results for multiple species or strains of an organism, only one unit of service of a CPT^® code may be reported for that test procedure. However, if separate medically reasonable and necessary test procedures are performed for different species or strains of an organism, the same CPT^® code may be reported for each test procedure using modifier 59 or XU for the second and additional test procedures.”

Key: “Before immediately appending modifier 59, always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It is extremely important to use the X{EPSU} modifiers accordingly.”