Wiki Modifier -59, XE in cardiology

[heartyoga]

We received a claims analysis letter from Amerigroup, stating that our provider fell outside of average utilization of the ff modifier. -59, XE

I queried our system and found the root cause.

Frequently our provider consults on cases, reads EKGs and echoes, stress test for the same patient, all same day service - so we bill as ff

99223-25
93010-59
93306-26-59
78452-26-XE

Are we overutilizing modifier -59?

What should be the correct way of using modifier -59?

Thanks!

 

[SharonCollachi]

Modifier 59 identifies procedures/services, other than E/M services and radiation treatment management, which are not normally reported together, but are appropriate under the circumstances. Documentation must support:

• a different session,
• different procedure or surgery,
• different site or organ system,
• separate incision/excision,
• separate lesion, or
• separate injury (or area of injury in extensive injuries)

Note: When another already established modifier is appropriate, report it instead of modifier 59. Use modifier 59 only if no other descriptive modifier is available.

Do not report modifier 59 or other NCCI-associated modifiers to bypass an edit unless documentation in the medical record supports its use.

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported.

Modifiers XE, XS, XP, XU defined
XE – “Separate encounter, 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.
XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

**********************************************************************************************************************************************************************************

It doesn't SEEM like what he is doing is a separate encounter (xe) nor does it SEEM like it meets the definition of modifier 59.

 

[thomas7331]

We received a claims analysis letter from Amerigroup, stating that our provider fell outside of average utilization of the ff modifier. -59, XE

I queried our system and found the root cause.

Frequently our provider consults on cases, reads EKGs and echoes, stress test for the same patient, all same day service - so we bill as ff

99223-25
93010-59
93306-26-59
78452-26-XE

Are we overutilizing modifier -59?

What should be the correct way of using modifier -59?

Thanks!

There's really no such thing as 'overutilizing' a modifier - you're either utilizing it correctly or incorrectly. Don't let the payer's threats mislead you - if your records support the modifiers, then you are fine.

In the example above, I'm assuming these were all performed for an inpatient in the hospital. In the hospital record, each test should show a separate order and a separate time when the test was actually performed. As long as you are not billing for something that was a component of another, then you should be fine. For example, the EKG 93010 cannot have been done concurrently with the echo 93306. (In most cases in the hospital, the EKG would have been done earlier during the day, perhaps in the ED prior to admission, and the results used for developing the plan of care for the additional tests, so the 59 would be appropriate if that is the case.)

Modifier XE is a questionable choice since technically speaking an inpatient stay is a single encounter. However, CMS has given some guidance that this modifier may be used to represent tests that were done in different departments within the hospital on the same day. So it may be OK, but the important thing is that you records show clearly that you are not using the modifier to inappropriately unbundle an incidental component of another test for additional reimbursement.

 

[heartyoga]

Thank you Tom.

Do we both -59 on one of the test or on both?

Scenario:
Inpatient EKG read 93010
Inpatient Echo read 93306-26

Do we put -59 only on one or the other?

Scenario:
In office echo 93306
same day as in office carotid 93880

Do we put -59 on both lines?

Thanks!

 

[thomas7331]

Thank you Tom.

Do we both -59 on one of the test or on both?

Scenario:
Inpatient EKG read 93010
Inpatient Echo read 93306-26

Do we put -59 only on one or the other?

Scenario:
In office echo 93306
same day as in office carotid 93880

Do we put -59 on both lines?

Thanks!

Modifier 59 goes on the code that is the component of the more extensive procedure - the column 2 code of the code pair in the NCCI table. It looks to me as those neither of these pairs has a bundling relationship in NCCI, so you should not need a modifier 59 in these particular examples.