Wiki XE Separate Encounter Meaning

sbosley

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I have a urologist that does cysto procedures in one op suite, then transfers the patient to a separate suite and performs a lithotripsy procedure. He states these are separate encounters due to the procedures being performed in separate suites.

Any thoughts? I have researched this and cannot find any solid guidance as to what is considered a "separate encounter"
 
From Noridian:

Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Moving from one suite to another does not constitute separate encounter. Separate encounter is service at one point during a 24 hour period and a second procedure later in the same 24 hours


The examples in that article reference the same concept.

That is the latest info I could find.
 
We are a family practice located in Hana Maui. We see a lot of tourist for urgent care (lacerations, fractures, dislocations etc) Our office is not an urgent or emergency room. The nearest ER is over 60 miles away. I have been adding the 99050 or 99058 code in additions to the E&M code and all other services rendered during the visit. But claims are denying or payment goes to the deductible and patient do not want to pay because it was urgent care. Has anyone have experience with this type of situation? If yes, how did you bill the visit? Did you get paid?
 
Thanks for the reply, but this is a blog from AAPC with examples. I am looking for concrete clarification from a governing body that develops coding rules, such as CMS or CPT guidelines. Where did you pull the "2nd procedure later in the same 24 hours" from? Everything I see just says "separate session/encounter". Technically, he is actually doing this procedure during a separate session, using a separate room, equipment, etc. Maybe this is applied by each payer differently? I have had some luck with appeals depending on the payer.
 
There are no articles/MLN with the exact definition of 'separate encounter'.
The example given in this article https://www.aapc.com/blog/40734-modifier-59-xespu-appropriate/ references a patient that has had a procedure and then has to be taken back in for another issue.

https://www.premera.com/paymentpolicies/cmi_051722.pdf
The definition in that medical policy defines separate encounter as 'Modifier XE: Separate Encounter – a service that is distinct because it occurred during a separate encounter (e.g. separate surgical sessions after discharged from surgical suite; different block of time resulting in no overlap of services)'. You may be able to use the 'different block of time with no overlap' as the basis of using XE, at least for Premera patients.
 
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