Otolaryngology Coding Alert

Some payers still want modifier 59, but others will crave specificity.

In 2015, Medicare created the X modifiers to replace modifier 59 (Distinct procedural services). Medicare made this move in order to make distinct procedural services coding more specific because CMS is concerned that physicians might be abusing the modifier.

With the X modifiers, Medicare believes it can curb the abuse because they’re more specific, forcing the physician to clarify why they are using the distinct procedural services modifier to unbundle two procedures and procure separate pay.

The X modifiers are:

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

Since their debut, adaptation of the new X modifiers has been inconsistent. Some payers want modifier 59, while others now require X modifiers for distinct procedural services.

Problem: Coders that have to contend with the X modifiers need more information in order to code correctly. If they don’t get enough info to choose between the X modifiers, the claim might not be paid completely.

Solution: We asked Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J., for examples of encounters for each of the X modifiers.

This month, we’ll look at the most common X modifiers: XE and XS. Otolaryngology practices will see these modifiers most often because otolaryngologists often encounter working during separate encounters or on separate structures,” Cobuzzi explains.

Check out these detailed examples of XE and XS use, and look for more X modifier scenarios in future issues of Otolaryngology Coding Alert.

Modifier XE example: The otolaryngologist sees an established patient in the office during the day and performs a diagnostic nasal endoscopy after an evaluation and management (E/M) service. That evening, the same otolaryngologist reports to the emergency department (ED) to treat the same patient for epistaxis. He performs complex nasal hemorrhage control using cautery and packing.

On the claim, you’d report:

Procedures

• 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) to represent the nasal endoscopy.
• 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) to represent the epistaxis control.
• Modifier XE appended to 30903 to show that the two procedures were distinct procedural service that the otolaryngologist performed during separate sessions.

E/M service

• The appropriate-level E/M code from the 9921- (Office or other outpatient visit for the evaluation and management of an established patient …) code set the represent the E/M service.
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the E/M code to show that the otolaryngologist performed a significant, separately identifiable E/M prior to the endoscopy.

Explanation: According to Cobuzzi, “a diagnostic nasal endoscopy is bundled into any control of epistaxis procedure.” If the physician sees a patient during the day in the office, performs a diagnostic nasal endoscopy, and then goes to the emergency department later in the day to treat that same patient for an epistaxis and performs 30903, you’ll need a modifier to separate the procedures, she explains, “even though they were performed at two different places of service.”

Takeaway: The provider performed the service during a different session. If the payer requires an X modifier in this instance, you would opt for the XE modifier.

Modifier XS example: The otolaryngologist performs an anterior ethmoidectomy on the patient’s left side and a total ethmoidectomy on her right side. On this claim, you’d report

• 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) for the right-sided ethmoidectomy.
• Modifier RT (Right side) appended to 31255 to indicate that the physician performed the procedure on the patient’s right side.
• 31254 (…  with ethmoidectomy, partial [anterior]) for the left-sided ethmoidectomy.
• Modifier LT (Left side) appended to 31254 to indicate that the physician performed the procedure on the patient’s left side.
• Modifier XS appended to 31254 to show that the physician performed 31254 and 31255 on separate structures.

Explanation: Typically, payers bundle 31254 into 31255. But since the physician performed these two procedures on different sides, and the LT and RT modifiers will not necessarily override the bundle, “one would use the XS for separate site for this situation,” Cobuzzi explains.