Urology Coding Alert

Hint: Modifier 58 is for staged procedures.

If you’ve ever wondered how to appropriately append modifiers to your claims, the recent Virtual HEALTHCON talk “Unbundling Modifiers: A Risky Business,” was the perfect session for you. Speaker Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of KnowledgeTree, Billing, Inc., discussed both evaluation and management (E/M) and procedure modifiers.

Read on to learn what she had to say about commonly misused procedure modifiers.

See Dangers of Misusing Modifiers

“Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code,” according to the Medicare Administrative Contractor (MAC) Novitas. “They [modifiers] are used to add information or change the description of service to improve accuracy or specificity.”

A modifier modifies the intention because there is a special circumstance of the CPT^® code you are reporting, but you are not actually changing the definition of the code itself, Vanderbilt explained.

When you misuse modifiers, several things can happen, according to Vanderbilt. First, you are put at risk of inappropriate reimbursement. This, in turn, puts you at risk of audits, which puts you at risk of treble damages.

Additionally, your providers are put at risk of losing their right to bill insurance, potentially losing their license or even jail time, she added. Coders are put at risk of losing their credentials and may face monetary penalties and also jail time.

Discover Modifier 59 and X{EPSU}Modifiers

A commonly misused modifier is modifier 59 (Distinct procedural service). According to the Centers for Medicare & Medicaid Services (CMS), “Modifier 59 is used to identify procedures services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support.”

A “distinct” procedural service can be described as the following, per Vanderbilt:

• A different session
• A completely different procedure or surgery
• A different site or organ system
• Separate incisions/excisions/separate lesions
• A separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

However, when another already established modifier is appropriate, it should be used rather than modifier 59, Vanderbilt explained.

These appropriate modifiers include the following:

• Laterality: RT (Right side), LT (Left side), 50 (Bilateral procedure)
• Fingers: FA (Left hand, thumb)-F9 (Right hand, fifth digit)
• Toes: TA (Left foot, great toe)-T9 (Right foot, fifth digit)
• Coronary artery- LC (Left circumflex coronary artery), LD (Left anterior descending coronary artery), LM (Left main coronary artery), RC (Right coronary artery), RI (Rasmus intermedius coronary artery)
• Eye Lid: E1 (Upper left, eyelid)-E4 (Lower right, eyelid)

If the anatomical modifiers apply, then modifier 59 should not be reported because the anatomical location is what would support the unbundling of those services, Vanderbilt explained.

X-modifiers: On the other hand, if anatomical modifiers don’t apply, you should be using the following X{EPSU} modifiers:

• XE (Separate encounter …). Modifier XE is used for a service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
• XP (Separate practitioner …). Modifier XP is used for a service that is distinct because a different practitioner performed it.
• XS (Separate structure …). Modifier XS is used for a service that is distinct because it was performed on a separate organ/structure.
• XU (Unusual non-overlapping service …). Modifier XU is used for a service that is distinct because it does not overlap usual components of the main service.

If you take modifier 59 out of the modifier world and the CPT^® world and consider it from an ICD-10-CM perspective, you will see that modifier 59 is unspecified, Vanderbilt explained. The X{EPSU} modifiers replace 59; they are the equivalent of reporting 59 with a higher level of specificity.

Caution: If the anatomical or X{EPSU} modifiers don’t apply, there’s a good likelihood that your service should not be unbundled, Vanderbilt said. That means that instead of two CPT^® codes, you should only report one.

Know When to Append Modifier 58

Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) is another commonly misused modifier.

The provider’s documentation should include identification of each stage of the surgery and plans for returning the patient to the operating room (OR) for additional procedures to manage the patient’s condition, according to Vanderbilt.

Burn care, urology surgeries/care, and spine surgeries are common types of stages surgeries.

Also, sometimes the procedure itself may be so extensive that the patient cannot handle being under anesthesia for that length of time, so it is more appropriate to have them undergo different sessions of the surgery, Vanderbilt added.

Some reasons for a staged procedure include the following:

• Allowing a patient time to heal from the first surgery
• Time for an infection to resolve
• Situations where the patient cannot tolerate multiple procedures during the operative session
• Multiple procedures are not appropriate in the same operative session

Focus on How to Properly Use Modifier 78

Modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) is another commonly misused modifier. Unlike modifier 58, which is used for a planned return to the OR, modifier 78 is for an unplanned return, Vanderbilt said.

Modifier 78: Modifier 58 is planned. Modifier 78 is an unplanned return by the same provider that is related to the procedure for which you are in the postoperative period.

Requirements for modifier 78 that you will see in the documentation include the following:

• The procedure is related to the initial procedure.
• It is not considered to be a repeat procedure.
• The return may be the result of a complication that the initial procedure caused.
• The return requires the use of an operating or procedure room.

Don’t miss: A new global period does not begin for the unplanned, related procedure because it is typically from a complication related to the initial procedure, Vanderbilt said.