Cardiology Coding Alert

Never append modifier 59 to an E/M service.

Whether you’ve been in the coding world for five or 15 years, you are probably familiar with modifier 59 (Distinct procedural service), also known as the “unbundling modifier.” But, when it comes to unbundling National Correct Coding Institute (CCI) procedure-to-procedure (PTP) edit pairs, you need to know all of the guidelines and your modifier options.

Take this quiz to ensure modifier 59 never trips you up again.

Grasp CMS’s Modifier 59 Guidelines

Question 1: Can you explain what rules CMS has for modifier 59?

Answer 1: You may use modifier 59 when you can document circumstances that result in the provider performing multiple procedures that don’t usually occur together.

CMS puts it this way in the Medicare Claims Processing Manual Chapter 23, (updated in Transmittal 4188 dated December 28, 2018):

• Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
• Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.
• Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

The manual goes on to document limited circumstances that warrant modifier-59 use for timed procedures or diagnostic and therapeutic procedures performed on the same day.

Resource: You can read the entire the transmittal at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf.

Mind the Correct Modifier Indicator

Question 2: Can you append modifier 59 when the modifier indicator of a PTP pair is “0?”

Answer 2: No. You can only append modifier 59, or any other modifier for that matter, to unbundle two procedures when the modifier indicator is 1. If it is 0, “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider,” according to CMS. (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

Discover Other Modifiers to Unbundle

Question 3: Is modifier 59 the only modifier you can append to unbundle procedures?

Answer 3: No. Modifier 59 is not the only modifier you can use to unbundle procedures. If the situation allows, you may be able to use modifiers for specific anatomic sites, including RT (Right side), LT (Left side) and modifiers for specific fingers (F1-F9 and FA) and toes (T1-T9 and TA).

Additionally, since 2015, you have also had the option to use one of the X{ESPU} modifiers CMS introduced to eventually replace 59:

• XE (Separate encounter)
• XS (Separate structure)
• XP (Separate practitioner)
• XU (Unusual non-overlapping service).

More and more payers are recognizing these modifiers, so be sure to check with them before using one when the situation allows.

Although CMS officially accepts these modifiers, you should ensure that your Medicare Administrative Contractor (MAC) processes claims using them before you report them.

“The X-modifiers better define why you feel the need to modify the service you are submitting,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “But it is important to understand the payer. What do they want to see? Do you need to send notes? And does the documentation clearly support the separate nature of the two services?”

Don’t Append Modifier 59 to E/M Services

Question 4: Can you use modifier 59 with evaluation and management (E/M) procedures.

Answer 4: No. “You would never use modifier 59 on an E/M service,” explains Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

If you’re overriding an edit pair that includes an E/M code, you should instead turn to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery).

Put it All Together With Cardiology Example

Question 5: I’m still not clear on when I can appropriately append modifier 59 for my cardiology services. Can you give me a specific example?

Answer 5: The cardiologist performs an electrocardiogram (EKG) and then decides the patient needs a stress echo the same day. The cardiologist is in an office setting and he provided all of the components of both tests. You would report the stress echo using 93351 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional). Then, you would report the EKG with 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).

Modifier alert: You’ll need to add a modifier to override the edit bundling 93000 into 93351. You may use modifier 59 (Distinct procedural service), XE (Separate encounter) or XU (Unusual non-overlapping service), depending upon your payer’s preference, explains Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee.

Make sure you only append with modifier XE if it’s truly a separate encounter like the patient must leave the office and returns later the same day, Neighbors adds. Report XU if the procedure is scheduled with a sub-specialist who does not have an individual UPIN # to perform this portion of the service. However, if a different physician within the same practice reads the stress echo portion of the exam, then that physician would report with modifier XP (Separate practitioner) as long as the physician takes full responsibility of the sub-specialist who performed the stress echo.