ED Coding and Reimbursement Alert

What would you do if 40 percent of your claims were billed incorrectly? For most providers, that would be practice-ending. Well, that’s the error rate that the Office of Inspector General (OIG) found when it audited modifier 59 (Distinct procedural service) claims.

• 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, the use of a service that is distinct because it does not overlap usual components of the main service)

Always go through your other options before adding modifier 59 to a code and ensure there isn’t one that’s more appropriate for your specific code pairs.

Error 2: Adding Modifier 59 to an E/M

You should never use modifier 59 on an evaluation and management (E/M) service. Scenarios like this require the use of modifiers 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), depending on encounter specifics.

In general, modifier 25 should be used on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period such as an injection; while procedures with a 90-day global period (such as fracture care or a surgery) will typically take modifier 57.

Error 3: When the Documentation Doesn’t Support ‘Separate and Distinct’ Nature

When you’re trying to decide whether you should append modifier 59, use a logical approach. Ask: Did the second procedure require a separate approach or site? If not, you probably cannot support medical necessity for the service.

Always make sure you’ve provided well-documented support for a separate and distinct procedure before adding modifier 59.

For example, if you repaired a nail bed on the patient’s left hand and repaired a wound on the patient’s right hand, you’d face denials if you reported these codes together, due to a National Correct Coding Initiative (NCCI) bundle of these two codes:

• 11760 (Repair of nail bed)
• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less)

However, if your documentation clearly notes that both procedures were medically necessary and that they addressed wounds on separate hands, you could append modifier 59 to 12001.

Error 4: When You’re Injecting the Same Drug Multiple Times

If you perform multiple injections of the same drug for the same patient on the same date, modifier 59 is not likely to help you get paid for the subsequent injections. Most payers instead prefer that you add the number of units instead. So instead of reporting 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)-59 for two injections of the same drug, you’d typically report it as 96372 x 2 units.

In some instances, the payer may prefer modifier 76 (Repeat procedure or service by same physician or other qualified health care professional), but most do not. Check with your insurer on how to report multiple administrations of the same drug.

Error 5: When the NCCI Indicator Is ‘0’

When the NCCI publishes its code pairs, each has a particular modifier indicator assigned to it. This indicator can be “0,” “1,” or “9.” Take a look at what these indicators mean:

• Indicator 0 — These codes should never be reported together by the same provider for the same beneficiary on the same date of service (DOS).
• Indicator 1 — These codes may be reported together only in defined circumstances (identified on claims by specific NCCI-associated modifier).
• Indicator 9 — Not relevant. The edit was deleted.

If a code pair is marked with indicator 0, you should never use modifier 59 to try and separate them.

For example, code 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) can never be payable with 62320 (Injection(s) ( of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance), even if you use a modifier to try and separate them. That’s because the code pair indicator for this edit is “0.”

FYI: You Can Now Use Modifier 59 for Multiple Rural Health Clinic Visits

If you’re accustomed to using modifier 59 regularly, you may be surprised to hear that payers do issue updated guidance for this modifier throughout the year. Always keep an eye on your payer transmissions to evaluate whether any modifier 59 updates may be tucked into the directives.

For example, one update came out earlier this year that affects how you may apply modifier 59 to your provider’s services at rural health clinics.

As most billers and coders are aware, if your provider sees a patient at a rural health clinic (RHC) or federally qualified health center (FQHC), you’ll be paid for one visit even if the patient sees the provider more than once on that date. You’ll typically bill T1015 (Clinic visit/encounter, all-inclusive) along with the CPT® or HCPCS codes that describe which services were provided.

Providers are typically paid as if they only saw the patient for one RHC or FQHC visit, even if the visits are long or complex, the patient sees multiple providers, or the visits are unrelated; and historically, no modifiers have been allowed to report a second payment for that date of service.

That changed this year, however, when CMS released a February 2024 MLN Fact Sheet noting that it would allow exceptions for instances when the patient suffers an illness or injury after the first visit that requires an additional diagnosis or treatment on the same day. In these situations, you can now use modifier 59 on the claim to show that you qualify for two billable visits.

Resource: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf.

Torrey Kim, Contributing Writer, Raleigh, N.C.