ED Coding and Reimbursement Alert

Check out these four new modifiers for 2015 as an alternative to reporting 59

Your coding for separate and distinct services next year in the ED will get at lot more interesting, as you’ll need to choose a specific code for the reason for the distinct service. 

The skinny: CMS released Transmittal 1422 in August which introduced four new HCPCS modifiers you can use starting Jan. 1, 2015.  The new modifiers replace modifier 59 (Distinct procedural service) to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.  

Good old -59: Often referred to as the modifier of last result, modifier -59 is defined in CPT® for use in a wide variety of circumstances, such as to identify: different sessions or encounters, different anatomic sites or organs, and distinct procedural services.  It should only be used if no other established modifier is appropriate, says Michael A. Granovsky, MD, FACEP, CPC, President of Logixheatlh, a national ED coding and billing company based in Bedford, MA. 

Modifier 59 should be used with procedures or non E/M services only.  Modifier 25 (Significant separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or service.) should be used with E/M services.in those circumstances.

Why The Change?

CMS says chronic overuse of the 59 modifier is the reason for the change, reporting that 59 is the most widely used HCPCS modifier. This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases when being used incorrectly to identify a distinct service.   According to the 2013 CERT Report data, $320 million was the projected error rate in physician fee schedule payments and an additional $450 million for facility payments.

The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place, says Granovsky. CMS believes that more precise coding options, coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment, he adds. 

Get Familiar With the X-Factor

CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the 59 modifier: 

• XE Separate Encounter (A Service That Is Distinct Because It Occurred During A Separate Encounter)
• XS Separate Structure (A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure) 
• XP Separate Practitioner (A Service That Is Distinct Because It Was Performed By A Different Practitioner) 
• XU Unusual Non-Overlapping Service, (The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service) 

According to Transmittal 1422, CMS will continue to recognize the 59 modifier. However, in certain instances, it may selectively require a more specific X{EPSU} modifier for billing certain codes at high risk for incorrect billing. 

For example, a particular NCCI PTP code pair may be identified as payable only with the XE separate encounter modifier but not the 59 or other X{EPSU} modifiers. The X{EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line. 

As a default for now, CMS will initially accept either a -59 modifier or a more selective X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. The agency may “selectively require” use of one of the new modifiers for certain codes that have a higher risk of incorrect billing

Please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.

Examples Guide Your X-Modifier Use in the ED

Check out these ED scenarios for the new modifiers that might add clarity:

Scenario One: A patient who receives multiple joint injections, one in the shoulder and one in the knee, both coded as 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). Some payers want modifier 76 (Repeat procedure), while others want modifier 59, Granovsky says. The new XS modifier for a different anatomical structure may be the best modifier to describe what happened.

Scenario Two: A patient presents to an urgent care center with a traumatic hip dislocation, and the FP working there tries to reduce injury, and then refers the patient to the ED for further treatment. While being transported to the ED, the hip dislocates a second time. The procedure is repeated later that day in the ED, where the emergency physician is successful. In this instance, the XE modifier for a separate encounter might be a more specific choice.

Keep in mind: Right now, these new X modifiers are for use by CMS, and it is unclear if other payers will incorporate the new modifiers, says Granovsky. 

Resources:

MLN Matters® Number: MM8863: www.cms.gov/Outreach-and-Education/Medicare.../MM8863.pdf

CMS Transmittal 1422: www.cms.gov/Regulations-and-Guidance/.../R1422OTN.pdf.