Ophthalmology and Optometry Coding Alert

Question: Can you explain when I should and shouldn’t append the X{EPSU} modifiers?

Louisiana Subscriber

Answer: It is appropriate to use the X{EPSU} modifiers when billing Medicare or payers following Medicare guidelines:

• For a different session or patient encounter, different surgery, different provider, different anatomical site, separate injury or area of injury, or an unusual non-overlapping service
• When the medical record documentation indicates two separate, distinct procedures performed on the same day by the same physician
• On the other hand, you should not use modifiers X{EPSU} under the following circumstances:
• If the code combination does not appear in the National Correct Coding Initiative (NCCI) edits
• If the edit pair has a modifier indicator of 0
• If the medical record documentation does not support the separate and distinct status
• If the provider performed the exact same procedure twice on the same day; instead, use modifier 76 (Repeat procedure or service by same physician …) or -77 (Repeat procedure by another physician …)
• When the documentation indicates the provider performed a procedure and an evaluation and management (E/M) service on the same date; in that case, you should look to an E/M modifier such as -25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service)

The X{EPSU} modifiers give greater reporting specificity in situations where you used modifier 59 (Distinct procedural service) previously. Append these modifiers instead of -59 whenever possible. Only use modifier 59 if no other more specific modifier is appropriate.

Note: Documentation is key when you are using modifiers. The supporting documentation must satisfy the criteria required.