Otolaryngology Coding Alert

Modifier 59 is still valid, but use the new modifiers instead when applicable.

While you’re keeping an eye out for coding updates and revisions coming next year, don’t fall in the trap of ignoring modifiers, however,  because some big changes are headed your way in 2015.

The scoop: CMS faces multiple issues when dealing with claims reporting modifier 59 (Distinct procedural service). The agency is attempting to solve those issues by introducing four new “X” modifiers that will replace modifier 59 in some instances for claims submitted to CMS. They are: 

• XE: Separate encounter (A service that is distinct because it occurred during a separate encounter)
• XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure)
• XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner)
• XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service). 

CMS announced the change in Transmittal R1422, issued on Aug. 15. Read on for their reasoning and what it might mean for your practice. 

Understand the CMS Perspective 

Modifier 59 can be used to separate CCI (Correct Coding Initiative) edits, but that’s not the only reason it’s available. 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 -59 in 2015. “CMS will not stop recognizing the 59 modifier but notes that CPT® instructions state that the 59 modifier 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. 

See How to Put the X(EPSU) Modifiers Into Practice

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 from 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., regarding how they’ll come into play for otolaryngologists. 

• XE (Separate encounter) – The physician performs a nasal endoscopy at 10 a.m. The patient goes to the ER at 8 p.m. that evening with severe epistaxis, so the doctor uses complex techniques to control the anterior epistaxis. “The diagnostic endoscopy is bundled with the control of epistaxis but they were done at different times,” Cobuzzi says. “The XE would be used.” 

• XS (Separate structure) – The surgeon completes nasal/sinus endoscopy on the left side that qualifies for 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and modifier LT (Left side). He also completes sinus endoscopy with maxillary antrostomy (31256, Nasal/sinus endoscopy, surgical, with maxillary antrostomy) on the right side. The procedures were completed during the same session but on different anatomic sites, so modifier XS would apply. You would report 31267-LT and 31256-XS-RT. 

• XP (Separate practitioner) – “This is an example of when one doctor in the group does a service and another practitioner in the practice does another service that’s bundled with the first,” Cobuzzi says. “It seems to me that if different practitioners do bundled services, there also would be other reasons for the separate nature, like separate encounter, separate site or unusual non overlapping services.”

• XU (Unusual non-overlapping service) –An otolaryngologist biopsies a suspicious lesion on the very posterior of the tongue and sends it for frozen section pathology.  While the patient is still under anesthesia, the frozen section comes back as malignant.  The surgeon then performs a glossectomy. While it is not usual for biopsies and resections to be both coded and billed, it is correct to code both when the biopsy is being performed for an unknown etiology (the surgeon has suspicions about the lesion, but no biopsies have been performed prior to this operative session). Both the glossectomy and the biopsy of the posterior tongue would be billed with a XU modifier on the biopsy code.

The big picture: “I feel that most situations fall under XE and XS situations,” Cobuzzi states. “I’ve always taught that the bulk of 59 modifier 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 the 59 modifier if you think it fits the situation better than these four alternatives. However, I think that using the 59 modifier when one of the X codes doesn’t apply may create red flags since there should be few instances when something does not fall under one of these four codes.“

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.