Pain Management Coding Alert

CMS introduces new options for some situations in 2015. 

Big changes are on the horizon for modifier 59 (Distinct procedural service) in January 2015. The modifier currently might be one of your go-to options when your provider performs multiple services during an encounter, but that could change with the New Year. 

What’s happening: 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. 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 some of our coding experts think it might mean for your practice. 

Watch When to Use – or Not Use – Modifier 59 

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. 

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 pain management. 

• 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. 
• XS (Separate structure) – The pain management specialist administers a right SI joint injection (27096-RT) and right intra-articular shoulder injection (20610-RT). The major joint injection took place at a separate anatomic structure from the SI joint injection. Therefore, you could compliantly bill both injections an include modifier XS with the 20610.
• 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). 
• 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 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 modifiers 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.