Pathology/Lab Coding Alert

You can stick with modifier 59 for now.

When you’re up against Medicare’s Correct Coding Initiative (CCI) edits for cases such as the following lung-cancer diagnosis scenario, you need to know how to differentiate distinct services so you get all the pay your pathologist deserves. 

Understand Bundling Rules

The case: The pathologist examines a liquid-based cytology slide from a bronchial alveolar lavage (BAL) specimen, and a fine needle aspiration (FNA) specimen from an enlarged mediastinal lymph node, assigning a diagnosis of lung adenocarcinoma.  

The solution: Report the BAL as 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid based slide preparation method], except cervical or vaginal) and the FNA evaluation as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report).

The problem: CCI bundles 88112 as a column 2 code with 88173, meaning that you should not report the two codes together, in many circumstances. 

The rules: You may be able to override CCI edit pairs if the pathologist documents that the specimens are from different sessions, different sites or organ systems, different incisions/excisions, or separate lesions that the pathologist would not normally encounter on the same day. The 88112 and 88173 specimens in this case meet the criteria for you to code both pathology services.

Use Modifier to Capture Both Services

To override a CCI edit pair in cases that warrant unbundling the services, you must report the bundled code with a modifier — in this case, 88112. 

The most common modifier that pathologists use in these cases is 59 (Distinct procedural service). 

But what about the following new modifiers that Medicare introduced, ostensibly to “replace” 59 as more specific modifiers:

• 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).

The start date for these modifiers was officially Jan. 1, 2015, and although some Part B MACs have offered a few examples to explain how to properly use the new X{EPSU} modifiers, CMS itself is still tight-lipped on the subject.

“In releasing the modifiers, we did not release instructions for the modifiers at that time the way CMS normally does,” noted Dan Duvall, MD, chief medical officer with CMS’s Center for Program Integrity at a CMS open door forum on the subject. 

Expect instructions soon: “CMS is working on additional guidance regarding [X{EPSU}] modifiers, as well as examples, and more definitive specifications on when to use those modifiers,” said National Government Services representative Andrea Freibauer during a recent “Part B Ask the Contractor Teleconference.”

Do this: Until further CMS instruction arrives, “You can use those X modifiers, [or] you can still feel free to use the 59 modifier as appropriate,” Freibauer said.

Currently, all of the X modifiers “have the same exact editing specifications as the 59,” Freibauer said. “If you aren’t comfortable using the X modifiers yet, it is absolutely fine to use the 59.”