Cardiology Coding Alert

Don’t rely on 59 for every distinct service.

When your cardiologist legitimately performs two bundled services for the same patient on the same day, you might be in the habit of appending modifier 59 (Distinct procedural service), to bring home the pay you deserve.

But that habit needs to stop once Jan. 1, 2015 rolls around. That’s because frequent modifier 59 misuse has driven CMS to create four new, more precise modifier options for reporting your distinct service claims. 

Read on to make sure you don’t get caught short and miss legitimate pay opportunities for your cardiology practice next year.

59 Separates ‘Distinct’ Services

Sometimes your cardiologist performs bundled procedures in a way that warrants separate reporting, such as different sessions or anatomic sites. You might be in the habit of using modifier 59 (Distinct procedural service) to override Correct Coding Initiative (CCI) edit pairs. 

But CMS says that many providers misuse modifier 59 for overriding edit pairs, making modifier 59 the source of a projected one-year error rate of $770 million (Transmittal R1422).

The problem: You should not use modifier 59 to get around the edits under many circumstances. And even if you meet the criteria to legitimately override an edit pair, you should not look to 59 as your first-choice modifier. 

“Modifier 59 is to be used when there is no better modifier choice,” says Lynn M. Anderanin, CPC,CPC-I, COSC, ICD10, senior director of coding compliance and education for Healthcare Information Services in Park Ridge, Ill.

CMS points out the following three common reasons for why you use modifier 59, along with the associated error odds, according to MLN Matters article MM8863:

• Infrequently used to identify a separate encounter, typically used correctly
• Less commonly utilized to define a separate anatomic site, less often used correctly
• Commonly used to define a distinct service, but frequently done so incorrectly.

Say Hello to “EPSU” Modifiers

Here’s how CMS explains the problem and the solution, according to an MLN Matters article.

Problem:“The 59 modifier often overrides the [CCI] edit in the exact circumstance for which CMS created it in the first place,” CMS states. 

Solution:“CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.”

To that end, CMS debuts the following new modifiers for 2015, known as the “X{EPSU}” modifiers:

• XE — Separate encounter, A service that is distinct because it occurred during a separate encounter
• XP — Separate practitioner, A service that is distinct because it was performed by a different practitioner
• XS — Separate structure,A service that is distinct because it was performed on a separate organ/structure
• XU — Unusual non-overlapping service, A service that is distinct because it does not overlap usual components of the main service.

Pick the Best-Fitting Modifier

Although the new modifiers will replace modifier 59 in specific instances, CMS won’t cease accepting 59 in 2015. But you should never use 59 and one of the X{EPSU} together for the same claim. That’s because the new modifiers define specific subsets of the 59.

“CMS will continue to recognize the 59 modifier in many instances, but may selectively require a more specific X{EPSU}modifier for billing certain codes at high risk for incorrect billing,” states the MLN Matters article.

Future:CMS eventually plans to institute edits that will allow the XE modifier to separate a specific CCI edit pair, but won’t accept modifier 59 or XU to separate that particular pair. As a way of easing into the new modifiers, CMS will initially accept either modifier 59 or the X{EPSU} modifier for a service. 

Alert: “The rapid migration of providers to the more selective modifier is encouraged,” theMLN Mattersarticle notes. In fact, MACs can start requiring the more specific modifiers in place of modifier 59 at their convenience, so keep an eye out for local requirements.

“I believe these modifiers will be required by the Medicare contractors,” says Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, director of coding operations-HIM at Allegheny Health Network in Pittsburgh, Pa. “From a private payer prospective, it will be interesting to see which payers follow suit. It makes sense from several different angles included statistical, patient outcomes based, reimbursement, and clean claims processes.”

Anticipate X{EPSU} Impact for Your Practice

Once the new modifiers go into effect, you can expect to change how your report together certain bundled services, when appropriate.

For instance: If your cardiologist inserts a Swan Ganz catheter to assess pressure in the pulmonary artery, and also inserts a non-tunneled central venous catheter in a separate vessel to administer medication, you might be able to report the two codes together despite a CCI edit that bundles the codes.

Do this: You’ll need to use a modifier to report both services together, because CCI bundles 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) as a column 2 code with 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes). Currently, you’d use modifier 59 to unbundle the services. With the advent of the X{EPSU} modifiers, you might choose XS next year instead of 59, depending on the payer. 

Look for payment impact:“I think [the new modifiers] will affect reimbursement,” says Monica Gourley, CCS, HCS-D, clinic coder at Klickitat Valley Health Services in Goldendale, Wash. 

Bottom line: If your cardiology practice was part of the myriad providers that CMS says has been erroneously using modifier 59, reporting the more specific modifiers could help you cut down on errors. And that could mean cleaner claims and audit protection, even if you see a near-term payment downside.

Resources:To read the transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf. To read the MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf.