General Surgery Coding Alert

Maybe you’ve recently received a payer notice regarding the use of modifier 59 (Distinct procedure service) or one of the X{EPSU} modifiers.

If so, your general surgery practice may not be alone. Read on for a refresher on how and when to use these modifiers, and for highlights of National Correct Coding Initiative (NCCI) 2020 Policy Manual changes that shed some light on the subject.

Remember 59 and X{EPSU} Basics

Frequent modifier 59 misuse propelled CMS in 2015 to create the following four new, more-precise modifier options, known as the “X{EPSU}” modifiers, for reporting distinct service claims:

• XE (Separate encounter) describes a service that is distinct because it occurred during a different patient encounter.
• XP (Separate practitioner) describes a service that is distinct because it was performed by a different healthcare provider.
• XS (Separate structure) describes a service that is distinct because it was performed on a different anatomic site.
• XU (Unusual non-overlapping service) describes a service that is distinct because it does not overlap with the usual components of the main service.

Avoid: You should never use 59 and one of the X{EPSU} modifiers together for the same claim, because they’re redundant. The X{EPSU} modifiers describe a specific subset of circumstances that would warrant using modifier 59.

Always: CPT^® instruction states that “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

NCCI relationship: The NCCI procedure-to-procedure (PTP) edits list code pairs of medical procedures that are “bundled” and would not normally be provided together for various reasons, such as one service is included in the other, or the services are mutually exclusive. When providers document special “distinct procedure” circumstances, CMS allows providers to override a PTP edit pair and bill both codes together by using the appropriate modifier, such as 59 or X{EPSU}.

Payer differences: As a provider, you might find that your specific Medicare Administrative Contractor (MAC) and other payers might have varying rules about using modifiers 59 and X{EPSU}. You’ll need to keep track of those rules and bill accordingly to facilitate claims processing for different payers.

Check Out NCCI 2020 Manual for Specific Surgical Examples

Although CMS initially stated the intention to phase out modifier 59 and encouraged providers to migrate to using the more selective modifiers, CMS still accepts modifier 59.

Update: The 2020 NCCI Policy Manual makes a move toward encouraging providers to use the more specific modifiers. By adding one of the X{EPSU} to the following examples (underlined added in 2020), CMS sheds light on how and when to use the modifier 59 alternatives:

• Chapter 3 Section E.1: CMS states that only one lesion removal code of any sort (destruction, debridement, paring/cutting, shaving, or excision) is appropriate for a single removal procedure, but “If multiple lesions are removed separately, it may be appropriate (depending upon the code descriptors) for the procedures to report multiple HCPCS/CPT^® codes using anatomic modifiers or modifier 59 or XS to indicate different sites or lesions. The manual repeats similar instructions for using XS in Section L 11 regarding biopsy bundled with excision, and in Section L 14 regarding biopsy codes 11102-11106 bundled with lesion destruction codes 17000 and 17004.
• In addition to modifier XS, the 2020 Policy Manual Chapter 3 update gives examples of using modifier XE for different patient encounters for skin or nail biopsy/ destruction/debridement/paring in Section E 3, Section L 14, and Section L 15.
• Chapter 3 Section G: CPT^® provides codes for intralesional injections of non-chemotherapeutic agents (11900-11901) and chemotherapeutic agents (96405-96406). “Two intralesional injection codes shall not be reported together unless separate lesions are injected with different agents, in which case modifier 59 or XS may be used.”
• Chapter 3 Section I.1: CMS states that primary graft/skin substitute codes (such as 15100, 15120, 15200, 15220) are mutually exclusive. “If multiple sites require different types of grafts/skin substitutes, the different … CPT^® codes should be reported with anatomic modifiers or modifier 59 or XS to indicate the different sites.”
• Chapter 5 Section D.7: CMS outlines conditions when you might separately report aneurysm repair and endarterectomy/bypass. “If both an aneurysm repair (e.g., after rupture) and a bypass are performed at separate non-contiguous sites, the aneurysm repair code and the bypass code may be reported with an anatomic modifier or modifier 59 or XS.”
• Chapter 6 Section E.5: Don’t report together recurrent and incisional hernia repair codes “unless a medically necessary incisional hernia repair is performed at a different site, [in which case], modifier 59 or XS should be used.”
• Chapter 6 Section E.6: Hernia mesh implantation code 49568 is bundled with all hernia repair codes other than incisional/ventral. “If a provider performs an incisional or ventral hernia repair with mesh/prosthesis implantation as well as another type of hernia repair at the same patient encounter, CPT^® code 49568 may be reported with modifier 59 or XS to bypass edits…”
• Chapter 6 Section H.9: If the surgeon treats hemorrhoids and at the same session, performs incision and drainage at a separate site, you may report both services by “appending an anatomic modifier or modifier 59 or XS.”
• Chapter 6 Section H.25: If the surgeon performs snare lesion removal during flexible colonoscopy (45385) and biopsy removal during flexible colonoscopy (45380), “Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier 59 or XE is only appropriate if the two procedures are performed at separate patient encounters.”

Key: “Before immediately appending modifier 59, always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It is extremely important to use the X{EPSU} modifiers accordingly.”

Resource: To view the current NCCI Policy Manual, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index?edirect=/NationalCorrectCodiNitEd/01_overview.asp, scroll to the bottom of the page, and click on the link.