Neurosurgery Coding Alert

CMS continues to accept modifier 59 but you should look for any available descriptive modifiers.

In the last issue, you learned that CMS is introducing new X modifiers to address issues in claims with modifier 59 (Distinct procedural service). Here is how this change is likely to impact your practice this year. Prepare to meet the change in Transmittal R1422 by following expert advice.

Watch When to Use – or Not Use – Modifier 59

Modifier 59 can be used to avoid CCI edits, but that’s not the only reason it’s utilized. According to Transmittal R1422, CMS states that many providers misuse modifier 59 for this purpose, leading it to be the source of a projected one-year error rate of $770 million.

CMS points out the following three common reasons that people use modifier 59, along with the associated error odds, according to MLN Matters article MM8863, issued on Aug. 15:

• 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.

“The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place,” the MLN Matters article says. “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 has debuted the new modifiers, known as the “X(EPSU)” modifiers.

Important: Although the new modifiers will replace modifier 59 in specific instances, CMS won’t cease accepting modifier 59 in 2015. “CMS will not stop recognizing the modifier 59 but notes that CPT® instructions state that the modifier 59 should not be used when a more descriptive modifier is available,” says the Transmittal, which has an effective date of Jan. 1, 2015. “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.”

Also note: CMS does not want you to play it safe and just add all the modifiers to each CCI edit you’re trying to separate. Therefore, you can’t report both the 59 modifier and an X(EPSU) modifier on the same line item.

“Keep in mind that a CMS modifier is not the same as an AMA CPT® modifier, as CMS modifiers would not be applicable to third party claims,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison. “You should also be aware that since modifier 59 is typically applied to another stand-alone procedure code, it will also have the effect of the multiple procedure rule with a 50% reduction in the allowable payment.”

Learn When the X (EPSU) Modifiers Could Apply

Being aware of the new modifiers is important, but knowing how to correctly report them day-to-day will have a direct impact on your reimbursement. Consider these examples of how the new modifiers might come into play for your practice.

• XE (Separate encounter) – Your provider performs diagnostic nerve conduction studies and EMG in the morning (codes 95905-XE and 95886). He then administers chemodenervation injections in multiple sites for treatment of chronic migraine in the afternoon (64615). The nerve conduction studies are bundled into the chemodenervation injections, but it’s appropriate to bill separately for both with the XE modifier since the physician performed the diagnostic studies in a different encounter.

• XP (Separate practitioner) – Dr. A places a brachial plexus catheter for continuous infusion for acute postoperative pain management following the patient’s shoulder surgery (64416-XP). His partner, Dr. B, refills and reprograms the patient’s intrathecal implantable infusion pump before she is discharged from the recovery area (62370).

• XS (Separate structure) – Your provider performs a lumbar laminectomy for stenosis at L45 (CPT® 63047) but a right L5S1 discectomy for disc displacement (CPT® 63030). These procedures are considered bundled services when performed at the same level, but are separately reportable when performed at separate levels. Therefore, you could compliantly bill both procedures and include modifier XS with CPT® 63030.

• XU (Unusual non-overlapping service) – During the same encounter, the physician performs a diagnostic EEG (95812-XU) and therapeutic greater occipital nerve block (64450).

“I feel that most situations fall under XE and XS situations,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “I’ve always taught that the bulk of modifier 59 usage is justified by separate encounters or separate sites.”

“Having the new modifiers makes you think and make sure you are meeting the definition and not just adding a 59 to get paid because the two codes are bundled,” she adds. “The transmittal said that these new modifiers do not cover all aspects when the 59 might be used, so you can still use modifier 59 if you think it fits the situation better than these four alternatives. However, I think that using modifier 59 when one of the X modifiers doesn’t apply may create red flags since there should be few instances when something does not fall under one of these four CMS modifiers.”

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