An Excellent Explanation of the XE-XU Modifiers However its not urged that you use the new modifiers at this time CMS will notify you when to start using them. ngsmedicare/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/modifiers/subsets%20of%20modifier%2059/!ut/p/a1/1VTbcpswEP0VXvLIaAER40eBXez4QtLGE8SLRwjhyBMEATm3r6_IrWlSJ82005lqGMGulrO3s0IZSlGm2JXcMC1rxS56OTtcYzIdO04EsySYAJDZiGCyjL0Ye-gMZSibJxGiUa2U4Fryne51210ru0LyHgjRoxeSNevP1aabJyGix6zVVviseQvElW70OaLmuBIGgrWC10oLpZW4PoAX6nu5qS8kv316W6LY8ftkLF03kncHUNWFLKVozWe3yzuhO6surSet5Q97pw2XBaKlU5TgD3O7ZGbDDOf28BByO8cuwIAPPbf0H_L_kUiKqKkY7FkEfqugP5l4SQAEfwlHo5NjLw7dR4N3XFATw2CvkwjQt0_m-AGg-wB4Fi3WJ6vxV2P9ppH0XT7QV2ygv-ICfcWXvxe_85_FD75jKBHh6QBPJm5yOvjThsar6dgUJJyt5itwpzH-NODRR7w2c-G2i2ixMbBMn9tSlTVKn4cRpXuG0fwnt5eXGTE3QT_2Nxql_-4qaKoq8B4fO4Wt31zdnRJCRB7ANSGTar1c2iwPbm98-h2UR4yQ/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?LOB=Part%20B&LOC=Connecticut&ngsLOB=Part%20B&ngsLOC=Connecticut&jurisdiction=Jurisdiction%20K Subsets of Modifier -59 On 1/1/2015, CMS CR8863 introduced the new subset modifiers of 59. Modifier 59 will still be valid; however, shall only be used for situations that do not fit the subset modifier descriptions. Modifier 59 is the most frequently applied modifier, but it is also the most misused. While the misuse may be unintentional at times, the improper coding leads to claims being paid incorrectly. As audits have increased, CMS has realized that more specific modifiers may be helpful to deter the misuse. With the new subset of modifiers, CMS believes their usage will help reduce overpayment when subset modifiers (XE, XS, XP and XU) are used appropriately. Modifier 59 - Distinct Procedural Service Modifier XE - Separate Encounter: A service that is distinct because it occurred during a separate encounter Modifier XS - Separate Structure: A service that is distinct because it was performed on a separate organ/structure Modifier XP- Separate Practitioner: A service that is distinct because it was performed by a different practitioner Modifier XU - Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service Modifier Use When... Do Not Use When... 59 There is no other appropriate modifier Documentation indicates two separate procedures performed on the same day by the same physician Documentation for the services represents a distinct procedural service and no other descriptive modifier is available, and the use of modifier 59 best explains the circumstances Modifier 59 is with the secondary, additional or lesser procedure of combinations listed in NCCI edits The second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service Code pairs are not part of the NCCI procedure to procedure edits Another valid modifier exists to identify and describe the separate services Submission of E&M codes Submission of weekly radiation therapy management codes (CPT code 77427) Documentation does not support the services were a distinct procedural service Multiple administration of injections of the same drug XE Coding pairs are part of the NCCI procedure to procedure edits Documentation indicates the services were provided during separate patient/provider encounter On the appropriate column 2 procedure code in the NCCI files There is no other modifier to describe the situation Code pairs are not part of the NCCI procedure to procedure edits Another valid modifier exists to identify and describe the separate services Submission of E&M codes Submission of weekly radiation therapy management codes (CPT code 77427) Documentation does not support the services were provided during a separate patient/provider encounter An exact same procedure code performed twice on the same day Multiple administration of injections of the same drug Submitted with modifier 59 XS Coding pairs are part of the NCCI procedure to procedure edits Documentation indicates that the service is distinct because it was performed on a separate organ/structure On the appropriate column 2 procedure code in the NCCI files There is no other modifier to describe the situation Code pairs are not part of the NCCI procedure to procedure edits Another valid modifier exists to identify and describe the separate services Submission of E&M codes Submission of weekly radiation therapy management codes (CPT code 77427) Documentation does not support the services were provided on a separate organ/structure An exact same procedure code performed twice on the same day Multiple administration of injections of the same drug Submitted with modifier 59 XP Coding pairs are part of the NCCI procedure to procedure edits Documentation indicates that the service is distinct because it was performed by a different practitioner On the appropriate column 2 procedure code in the NCCI files There is no other modifier to describe the situation Code pairs are not part of the NCCI procedure to procedure edits Another valid modifier exists to identify and describe the separate services Submission of E&M codes Submission of weekly radiation therapy management codes (CPT code 77427) Documentation does not support the services performed by a different practitioner An exact same procedure code performed twice on the same day Multiple administration of injections of the same drug Submitted with modifier 59 XU Coding pairs are part of the NCCI procedure to procedure edits Documentation indicates that the service is distinct because it does not overlap usual components of the main service On the appropriate column 2 procedure code in the NCCI files There is no other modifier to describe the situation Code pairs are not part of the NCCI procedure to procedure edits Another valid modifier exists to identify the separate services Submission of E&M codes Submission of weekly radiation therapy management codes (CPT code 77427) Documentation does not support an overlap and usual components of the main service An exact same procedure code performed twice on the same day Multiple administration of injections of the same drug Submitted with modifier 59 Modifier Scenarios Modifiers XE, XS, XP, XU and/or 59 will not bypass multiple surgery fee reductions guidelines and/or the bilateral fee adjustments guidelines. Note: 59 shall be the modifier of last resort. Modifier Scenario Rationale Example 59 Patient is seen to remove several and different benign skin lesions Same encounter Same organ system/structure(skin) Different lesions Excision of lesion (0.6 cm) 11401 Excision of lesion (1.0 cm) 11401-59 XE Patient is seen in the outpatient infusion center at 8:00 a.m. and seen again in the outpatient infusion center for another treatment at 6:00 p.m. Patient seen in the morning for a cardiovascular stress test and then later in the day patient returns for a rhythm ECG Separate encounter Antibiotic intravenous infusion 96365 Antibiotic intravenous infusion 96365-XE Cardiovascular stress test 93015 Rhythm ECG 93040-XE XS Patient seen for destruction and during procedure unrelated to the destruction the physician obtains tissue for pathologic examination Patient under goes a laparoscopy, surgical, ablation of one or more liver tumor(s) AND During the surgery, patient has ultrasonic guidance for needle placement Separate Structure (Note: that cannot be defined by anatomical modifiers) Destruction of premalignant lesion 17000 Skin biopsy 11100-XS Laparoscopy 47370 Ultrasonic guidance for needle placement imaging supervision and interpretation 76942-XS XP Patient undergoes a hernia repair at 7:00 a.m. Later in the day the patient develops acute abdominal pain and returns for another physician to perform a surgical laparoscopic appendectomy Separate practitioner Laparoscopic hernia repair 49650 Laparoscopic appendectomy 44970-XP XU Patient seen for two separate lesions; a lipoma is excised on upper thigh region (3 cm), and a separate lipoma excised on the lower leg region (less than 3 cm) Unusual and nonoverlapping Excision soft tissue tumor of thigh/knee region (3 cm) 27337 Excision soft tissue tumor of lower leg region (less than 3 cm) 27237-XU
Posted on: Mon, 26 Jan 2015 22:22:55 +0000
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