Wiki 52344 Bundles??

[RainyDaze]

Hi All,

My physician performed a ureteral dilation, lithotripsy and a stent placement. It looks like 52344 bundles into 52356, you can use a 59 to break the bundle. My question is what when is it acceptable to use the 59? Is it only when performed on different sides??? Here is a description of his procedure. Thanks for your help.


POSTOPERATIVE DIAGNOSIS:
Large distal right ureteral stone with secondary hydronephrosis.
Distal ureteral stricture preventing passage.

OPERATIVE PROCEDURE: Right ureteroscopy, ureteral dilatation of stricture, holmium laser lithotripsy, and double-J stent placement.

INTRAOPERATIVE FINDINGS: There were, in fact, 2 stones in the distal right ureter, 3 mm and 7 mm, unable to pass due to a discrete narrowing of the distal ureter, which required dilatation. The patient has smaller stones in the right kidney, which did not need to be treated at this time. Will check a 24-hour urine postoperatively.

OPERATIVE PROCEDURE: The patient underwent smooth induction of general anesthesia, after, SCD stockings placed, given IV antibiotics, placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion. Cystoscopy showed a normal anterior and posterior urethra with some moderate obstruction from the lateral lobes of the prostate. Bladder appeared normal. Ureteral orifices were orthotopic. Right ureteral orifice intubated with a sensor guidewire into the renal pelvis. Semirigid ureteroscopy was successful passing the ureteral orifice; however, about 2-3 cm proximal from the ureteral orifice, there was a discrete narrowing consistent with a ureteral stricture, and I could see the stone just proximal to this stricture. This was gently dilated, allowing me to access the stones, which were treated with the holmium laser. These stones were brown and hard, consistent with a calcium oxalate monohydrate composition, requiring a higher energy level of more than 8000 kilojoules to break up these 2 stones with minimal urothelial trauma. A 6 French x 28 cm double-J stent was then passed over a guidewire, with good position confirmed on fluoroscopy. Bladder emptied, and the cystoscope removed. The patient tolerated the procedure quite well. The patient will follow up with me in 1-2 weeks for cystoscopy and stent removal.

 

[nanettelhea]

Does anyone have any advice for the above question? I have the same situation.

 

[Nreed]

For your particular scenario, 52356 encompasses everything. I would not use the 59 modifier to bypass any edit because your document would not support the criteria.

Taken from CMS here: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf
Don’t use modifiers 59, XE, XS, XP, or XU, and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. Medical documentation must support the use of the modifier.

Appropriate & Inappropriate Use of These Modifiers
1. Using modifiers 59 or XS properly for different anatomic sites during the same encounter only when procedures which aren’t ordinarily performed or encountered on the same day are performed on:● Different organs, or● Different anatomic regions, or● In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

Modifiers 59 or XS are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that:● Are performed at different anatomic sites,● Aren’t ordinarily performed or encountered on the same day, and● Can’t be described by one of the more specific anatomic NCCI PTP-associated modifiers – that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI (See examples 1, 2, and 3 below.) From an NCCI program perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ.

We created NCCI edits to prevent the inappropriate billing of lesions and sites that aren’t considered separate and distinct. Treatment of contiguous structures in the same organ or anatomic region doesn’t generally constitute treatment of different anatomic sites. For example:● Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site (See example 4 below.)● Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site (See example 5 below.)

2. Only use modifiers 59 or XE if no other modifier more properly describes the relationship of the 2 procedure codesAnother common use of modifiers 59 or XE is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed during different patient encounters on the same day that can’t be described by 1 of the more specific NCCI PTP-associated modifiers – that is, 24, 25, 27, 57, 58, 78, 79, or 91 (See example 7 below.)

3. Don’t use modifiers 59 or XU just because the code descriptors of the 2 codes are different. One of the common misuses of modifier 59 relates to the part of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the 2 codes of a code pair edit describe different procedures, even though they may overlap. Don’t report the 2 codes together if they’re performed at the same anatomic site and same patient encounter, because they aren’t considered “separate and distinct.” Don’t use modifiers 59 or XU to bypass a PTP edit based on the 2 codes being “different procedures.” (See example 8 below) However, if you perform 2 procedures at separate anatomic sites or at separate patient encounters on the same DOS, you may use modifiers 59, XE, or XS to show that they’re different procedures on that DOS. Also, there may be limited circumstances sometimes identified in the Medicare NCCI Policy Manual when you may report the two codes of an edit pair together with modifiers 59, XE, or XS when performed at the same patient encounter or at the same anatomic site

 

[Nreed]

Does anyone have any advice for the above question? I have the same situation.

I apologize, I didn't click to reply to your question in the proper space.

For your particular scenario, 52356 encompasses everything. I would not use the 59 modifier to bypass any edit because your document would not support the criteria.

Taken from CMS here: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf
Don’t use modifiers 59, XE, XS, XP, or XU, and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. Medical documentation must support the use of the modifier.

Appropriate & Inappropriate Use of These Modifiers
1. Using modifiers 59 or XS properly for different anatomic sites during the same encounter only when procedures which aren’t ordinarily performed or encountered on the same day are performed on:● Different organs, or● Different anatomic regions, or● In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

Modifiers 59 or XS are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that:● Are performed at different anatomic sites,● Aren’t ordinarily performed or encountered on the same day, and● Can’t be described by one of the more specific anatomic NCCI PTP-associated modifiers – that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI (See examples 1, 2, and 3 below.) From an NCCI program perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ.

We created NCCI edits to prevent the inappropriate billing of lesions and sites that aren’t considered separate and distinct. Treatment of contiguous structures in the same organ or anatomic region doesn’t generally constitute treatment of different anatomic sites. For example:● Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site (See example 4 below.)● Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site (See example 5 below.)

2. Only use modifiers 59 or XE if no other modifier more properly describes the relationship of the 2 procedure codesAnother common use of modifiers 59 or XE is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed during different patient encounters on the same day that can’t be described by 1 of the more specific NCCI PTP-associated modifiers – that is, 24, 25, 27, 57, 58, 78, 79, or 91 (See example 7 below.)

3. Don’t use modifiers 59 or XU just because the code descriptors of the 2 codes are different. One of the common misuses of modifier 59 relates to the part of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the 2 codes of a code pair edit describe different procedures, even though they may overlap. Don’t report the 2 codes together if they’re performed at the same anatomic site and same patient encounter, because they aren’t considered “separate and distinct.” Don’t use modifiers 59 or XU to bypass a PTP edit based on the 2 codes being “different procedures.” (See example 8 below) However, if you perform 2 procedures at separate anatomic sites or at separate patient encounters on the same DOS, you may use modifiers 59, XE, or XS to show that they’re different procedures on that DOS. Also, there may be limited circumstances sometimes identified in the Medicare NCCI Policy Manual when you may report the two codes of an edit pair together with modifiers 59, XE, or XS when performed at the same patient encounter or at the same anatomic site