Medicare Compliance & Reimbursement

Choosing an alternative to modifier 59 is now easier.

While the Centers for Medicare & Medicaid Services (CMS) has not been particularly forthcoming about how to use Medicare’s new “X{EPSU}” modifiers, the MACs have begun offering case studies to help you understand how to use them.

As we reported in Medicare Compliance & Reimbursement, vol. 41, no. 3, WPS Medicare updated its “Modifiers Fact Sheet” to reflect some tips on using the new modifiers, now NGS Medicare and Part B payer Novitas have stepped in with some solid examples, as follows:

• Modifier XE (Separate encounter): Patient is seen in the morning for a cardiovascular stress test and then later in the day, the patient returns for a rhythm ECG. In this situation, you’d report 93015 for the stress test, along with 93040-XE for the ECG, NGS says.

• Modifier XS (Separate structure): Physician destroys a pre-malignant lesion and then obtains tissue for a biopsy unrelated to the destruction. You’ll report 17000 for the lesion destruction along with 11100-XS for the biopsy.

• Modifier XP (Separate practitioner): Surgeon A performs a hernia repair at 7:00 a.m. Later that day, a different doctor performs an appendectomy. Surgeon A reports 49650 for the hernia repair and physician B reports 44970-XP for the appendectomy, NGS advises.

• Modifier XU (unusual non-overlapping service): The physician excises a 2.8 cm lesion on the patient’s upper thigh area and then excises a separate 2.5 cm lipoma on the lower leg region. You’ll report 27327 for the first excision and 27618-XU for the second.

• Modifier 59 (Distinct procedural service): This continues to be the modifier of last resort, which

means you’ll only use it when none of the modifiers above apply to your situation.

“We do expect that we’ll start off seeing more information coming from CMS in the future, they’re looking to see how things go with the reporting of these modifiers before they take another step and further clarify these or make actual changes to policy,” said NGS Medicare’s Nathan L. Kennedy, Jr., CPC, CHC, CPPM, CPC-I, during the MAC’s Jan. 27 online conference, “J6 January Quarterly Release Webinar.”

“These modifiers were highly anticipated to go into effect,” Kennedy added. “Modifier 59 has always been kind of a catch-all or a generic modifier to try and catch several different things, so CMS decided it was necessary to create more specific modifiers to report services, more distinctly than modifier 59 did.”

Resource: For more on using the new modifiers, visit www.ngsmedicare.com.

More Modifier X{EPSU} Examples Trickle Forward

Novitas has offered the most comprehensive examples yet. For example, Novitas suggests that you can scrap using modifiers 59 (Distinct procedural service), LT (Left side) or RT (Right side) if the doctor performs an arthroscopic rotator cuff repair and an arthroscopic partial synovectomy during the same session. Instead, “modifier XE (Separate encounter) may be more appropriate” in this situation, the payer says.

Therefore, you’d report this service using 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) followed by 29820-XE (Arthroscopy, shoulder, surgical; synovectomy, partial).

To read Novitas’ complete advice and examples, visit www.novitas-solutions.com.