Orthopedic Coding Alert

Nail down your modifier 59 alternatives with these scenarios.

CMS has been slow to offer examples on how to use Medicare’s new “X{EPSU}” modifiers, but a few carriers are slowly but surely stepping in to share advice on their proper usage.

As we reported in Orthopedic Coding Alert v. 17 n 9, CMS rolled out four new HCPCS modifiers, known as the “X{EPSU}” modifiers, to substitute for modifier 59 (Distinct procedural service) when appropriate. However, many orthopedic practices expressed frustration about the dearth of information about how to use the new modifiers. Fortunately, several Medicare administrative contractors (MACs) have begun putting examples in black and white to help guide your choices.

WPS Medicare updated its “Modifiers Fact Sheet” to reflect some tips on using the new modifiers in January, while Noridian, NGS Medicare and Novitas Solutions stepped in with some solid examples as well. Several scenarios on the appropriate modifier usage are as follows:

Modifier XS (Separate Structure)

It may surprise you to know that modifier XS does not apply to cases where the practitioner addresses a separate incision/excision, separate lesion, or separate injury. Modifier XS “is only for separate organ or structure,” Noridian says. “If providers have any of these other situations, continue billing with modifier 59,” the payer notes.

Example: The physician cuts benign hyperkeratotic lesions from the patient’s heel, and then also performs nail debridement. In this situation, you could report 11055 along with 11720-XS, Novitas says.

Modifier XE (Separate Encounter)

When asked to explain the difference between modifier XE (Separate encounter) and modifier XS (Separate structure), Noridian advised that XE involves a separate encounter, which “means at two different times; e.g. once in the morning and again in the afternoon as an example.” Modifier XS, on the other hand, refers to a procedure performed on a “separate structure or organ.” So think of XE is a different time of day and XS as a different organ.

Modifier XP (Separate Practitioner)

Noridian explains that modifier XE is only applicable if the same provider is performing both services, but at different times of day. Modifier XP (Separate practitioner), however, should only be used if different providers from the same group are performing the two services, Noridian says.

Example: Dr. Smith performs a shoulder injection (64415) at 7:00 a.m. Later that day, his partner Dr. Thomas performs an appendectomy. Dr. Thomas reports 44970 for the appendectomy and Dr. Smith reports 64415-XP for the shoulder injection.

Modifier XU (Unusual Non-Overlapping Service)

You’ll use modifier XU to represent situations that don’t happen often but that will trigger CCI edits. You can use XU “when a diagnostic procedure occurs subsequent to a completed therapeutic procedure and when the diagnostic procedure is not a commonly accepted or necessary follow up to the therapeutic procedure,” Noridian says.

For example, the physician destroys a benign lesion and then also biospies subcutaneous tissue. You can report 17000 followed by 11100-XU, Novitas Solutions suggests.

Modifier 59

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.

Example: A physical therapist performs two different therapy interventions (coded with 97140 and 97530) at the same session, which violate CCI edits. In this situation, “modifier 59 is the best modifier to use,” Noridian says.

Keep Looking for Official Guidance

“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, “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.”