Coding & Reimbursement

Most used, misused and abused

CMS provides alternatives to modifier 59.

By Suzanne L. Corcoran

Modifier 59 is commonly called the “unbundling” modifier. It is both one of the most frequently used modifiers and the most misused. To rectify that, CMS has introduced new “X” modifiers for physicians and coders to learn.

Q: How does CPT define modifier 59?

A: CPT defines modifier 59 as a “Distinct Procedural Service.” CPT explains: “Modifier 59 is used to identify procedures or services, other than E/M services, that 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 or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

Q: When should I use modifier 59?

A: Use modifier 59 when a procedure or service includes two or more CPT codes that are bundled under Medicare’s National Correct Coding Initiative (NCCI) edits, yet circumstances support separate charges. It’s not commonly used in eye care.

Q: But modifier 59 is appropriate when procedures are preplanned and have distinct indications, correct?

A: No. CMS published a clarification stating, “Use of modifier 59…does not require a different diagnosis for each HCPCS/CPT code procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.”

Q: Are different areas of the retina (for example, macula and peripheral retina) considered different anatomic sites?

A: No. The CMS clarification is specific and states, “The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ…Treatment of posterior segment structures in the eye constitute a single anatomic site.”

Q: What are the new “X” modifiers?

A: CMS established four new HCPCS modifiers, effective Jan. 1, 2015. They are:

• XE - Separate encounter

• XS - Separate structure

• XP - Separate practitioner

• XU - Unusual nonoverlapping service

The new modifiers are a more selective version of modifier 59. Their use will allow tracking of the various reasons this modifier is used or abused. CMS noted, “… that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.” The use of modifiers 59 or X{EPSU} on a claim indicates that documentation is in the patient’s record that will support the distinct nature of the service.

Q: When are these modifiers used?

A: All are used in distinct situations.

Modifier XE should only be used to describe separate encounters on the same date of service. For example, you do an exam and perform gonioscopy (92020) for a patient with uncontrolled POAG in your office in the morning. You do laser trabeculoplasty (LT, 65855) at the hospital later the same day. NCCI edits bundle 92020 with 65855. Your claim will append modifier XE (or 59) to the claim for 92020 performed in the office; do not bill separately for use of the goniolens with the LT.

Modifier XS describes a service that is distinct because it was performed on a separate organ or structure. An example might be same-day cataract surgery (66984) on the right eye and YAG laser capsulotomy (66821) on the left eye. Your claim will append modifier XS (or 59) to 66821, since it is normally bundled with 66984.

Modifier XP describes a service that is distinct because a different practitioner performed it. For example, your pediatric ophthalmologist examines a premature infant in the NICU and performs extended ophthalmoscopy (92225); she finds ROP. Later the same day, her partner, a retina specialist, performs ROP laser (67229) on the same eye. Modifier XP is appended to 92225 to indicate that the two procedures are distinct because different physicians performed them (even though they are from the same practice). Note: Depending on the payer, you may also need to append modifier XP to the exam since the exam is also usually bundled with a laser.

Modifier XU is the most difficult and its use in ophthalmology likely to be infrequent. CMS says it describes a service that is distinct because it does not overlap usual components of the main service, such as when a diagnostic procedure is performed and then a decision is made to perform a therapeutic/surgical procedure.

Q: May modifier 59 or the X modifiers be used with other modifiers?

A: Not usually. The CPT definition states, “…when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used.” An exception is made for the use of informational modifiers (for example, RT, LT, E#). OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.