Question XP and XE Modifiers - bill on each encounter? - Mental health

[TMacFarlane]

Hi,

I am unclear if we should be using XE and XP ( on each code for each encounter that qualifies. )

For example:
Patient comes in and has all these services same day, one service by a different provider:

T1017 1 unit 15 min - Case Manager A
90834 therapy session - Therapist B
T1017 3 units 45 min - Case Manager A, again

Would it be billed as:
Line 1: T1017 XE? XP? (unsure if this needs modifiers at all since its the initial encounter)
Line 2: 90834 XE? XP (Must have the XP since saw an additional provider, but not sure if needs XE since the below covers the extra encounter)
Line 3: T1017 XE XP (Must have the XE as the subsequent encounter, not sure if needs the XP, since the above covers the additional provider)

Thanks!

 

[sls314]

Hi,

I am unclear if we should be using XE and XP ( on each code for each encounter that qualifies. )

For example:
Patient comes in and has all these services same day, one service by a different provider:

T1017 1 unit 15 min - Case Manager A
90834 therapy session - Therapist B
T1017 3 units 45 min - Case Manager A, again

Would it be billed as:
Line 1: T1017 XE? XP? (unsure if this needs modifiers at all since its the initial encounter)
Line 2: 90834 XE? XP (Must have the XP since saw an additional provider, but not sure if needs XE since the below covers the extra encounter)
Line 3: T1017 XE XP (Must have the XE as the subsequent encounter, not sure if needs the XP, since the above covers the additional provider)

Thanks!

There is no CCI conflict between T1017 and 90834, so you should not be using X modifiers on those codes. (The X modifiers are used for the purpose of overriding CCI conflict between codes.)

I don't see any published quantity or MUE limits on T1017, so I wouldn't generally anticipate an issue with billing 4 total units provided by Case Manager A.

 

[TMacFarlane]

There is no CCI conflict between T1017 and 90834, so you should not be using X modifiers on those codes. (The X modifiers are used for the purpose of overriding CCI conflict between codes.)

I don't see any published quantity or MUE limits on T1017, so I wouldn't generally anticipate an issue with billing 4 total units provided by Case Manager A.

So what X modifiers (or 59/76) would you add on these?

Same patient, same day, Line 2 different provider than line 1 and 3:
Line 1: T1017
Line 2: 90834
Line 3: T1017

Thanks!

 

[sls314]

So what X modifiers (or 59/76) would you add on these?

Same patient, same day, Line 2 different provider than line 1 and 3:
Line 1: T1017
Line 2: 90834
Line 3: T1017

Thanks!

Are you looking for modifiers because you're getting denials when billing the codes together? Generally, those codes shouldn't need any of the modifiers that you listed.

Some payers may want one of the behavioral H modifiers to specify what level of credential the performing provider was. I know Medicaid in my state requires those. Or if the services were provided via telehealth, you'd need to specify that. However, you wouldn't need any of the CCI modifiers (X modifiers or 59) because there's no CCI edit for the code.

If you're getting denials for missing modifiers, it could be one of the H modifiers that's needed. Hard to say without knowing the payer and the denial reason.

 

[TMacFarlane]

Are you looking for modifiers because you're getting denials when billing the codes together? Generally, those codes shouldn't need any of the modifiers that you listed.

Some payers may want one of the behavioral H modifiers to specify what level of credential the performing provider was. I know Medicaid in my state requires those. Or if the services were provided via telehealth, you'd need to specify that. However, you wouldn't need any of the CCI modifiers (X modifiers or 59) because there's no CCI edit for the code.

If you're getting denials for missing modifiers, it could be one of the H modifiers that's needed. Hard to say without knowing the payer and the denial reason.

Yes, Idaho Medicaid (optum) denied the 2nd T1017 billing same day service, by the same provider as the first service, because it didnt have the XE/59 modifier for the extra encounter. I'm trying to research if all of the codes for the entire day for that patient need XE, in addition to, XP for any of those XE's that were extra providers.

Thanks

 

[sls314]

Yes, Idaho Medicaid (optum) denied the 2nd T1017 billing same day service, by the same provider as the first service, because it didnt have the XE/59 modifier for the extra encounter. I'm trying to research if all of the codes for the entire day for that patient need XE, in addition to, XP for any of those XE's that were extra providers.

Thanks

Are you not able to bill on 1 line with 4 units? Given that the definition of the code states "each 15 minutes" and the same provider is seeing the patient on the same day for 1 total hour, I'm not clear why the services have to be split onto 2 lines.

Admittedly, I don't bill for T1017. However, I just checked a few references and can't find any reason why a time based code would have to be split onto 2 lines when it's the same provider on the same day.

As long as the visit notes clearly demonstrate that the same provider saw the same patient for one total hour on the same day, I'd consider billing T1017 x 4 units.

 

[sls314]

I should add that I have checked the Idaho Medicaid (Optum) provider manual as well.

If the reason you're billing on separate lines is that one is Care Coordination and the other is Targeted Care Coordination, according to the provider manual the Targeted Care Coordination should be billed with a U3 or U2 modifier. (see page 118 of the Provider Manual PDF that I linked below):

https://www.optumidaho.com/content/dam/ops-optidaho/idaho/docs/alerts/2019alerts/20191201_ProviderAlert_CaseManagement.pdf