Podiatry Coding & Billing Alert

Remember: Modifier 58 is appropriate for staged procedures.

It can be challenging to know under which circumstances you can append modifiers. In the recent Virtual HEALTHCON talk “Unbundling Modifiers: A Risky Business,” speaker Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of KnowledgeTree, Billing, Inc., talked about commonly misused procedure modifiers.

Check out the following tips to always use modifiers correctly in your podiatry practice.

Tip 1: Observe Dangers of Modifier Misuse

“Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code,” according to the Medicare Administrative Contractor (MAC) Novitas. “They [modifiers] are used to add information or change the description of service to improve accuracy or specificity.”

A modifier modifies the intention because there is a special circumstance of the CPT^® code you are reporting, but you are not actually changing the definition of the code itself, Vanderbilt explained.

When you misuse modifiers, several things can happen, according to Vanderbilt. First, you are put at risk of inappropriate reimbursement. This, in turn, puts you at risk of audits, which puts you at risk of treble damages.

Additionally, your providers are put at risk of losing their right to bill insurance, potentially losing their license, or even jail time, she added. Coders are put at risk of losing their credentials and may face monetary penalties and also jail time.

Tip 2: See When to Use Modifier 59, X{EPSU}Modifiers

A commonly misused modifier is modifier 59 (Distinct procedural service). According to the Centers for Medicare & Medicaid Services (CMS), “Modifier 59 is used to identify procedures services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support.”

• A “distinct” procedural service can be described as the following, per Vanderbilt:
• A different session
• A completely different procedure or surgery
• A different site or organ system
• Separate incisions/excisions/separate lesions
• A separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual

However, when another already established modifier is appropriate, it should be used rather than modifier 59, Vanderbilt explained.

These appropriate modifiers include the following:

• Laterality: RT (Right side), LT (Left side), 50 (Bilateral procedure)
• Fingers: FA (Left hand, thumb)-F9 (Right hand, fifth digit)
• Toes: TA (Left foot, great toe)-T9 (Right foot, fifth digit)
• Coronary artery- LC (Left circumflex coronary artery), LD (Left anterior descending coronary artery), LM (Left main coronary artery), RC (Right coronary artery), RI (Ramus intermedius coronary artery)
• Eyelid: E1 (Upper left, eyelid)-E4 (Lower right, eyelid)

If the anatomical modifiers apply, then modifier 59 should not be reported because the anatomical location is what would support the unbundling of those services, Vanderbilt explained.

X-modifiers: On the other hand, if anatomical modifiers don’t apply, you should be using the following X{EPSU} modifiers:

• XE (Separate encounter …). Modifier XE is used for a service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
• XP (Separate practitioner …). Modifier XP is used for a service that is distinct because a different practitioner performed it.
• XS (Separate structure …). Modifier XS is used for a service that is distinct because it was performed on a separate organ/structure.
• XU (Unusual non-overlapping service …). Modifier XU is used for a service that is distinct because it does not overlap usual components of the main service.

If you take modifier 59 out of the modifier world and the CPT^® world and consider it from an ICD-10-CM perspective, you will see that modifier 59 is unspecified, Vanderbilt explained. The X{EPSU} modifiers replace 59; they are the equivalent of reporting 59 with a higher level of specificity.

Caution: If the anatomical or X{EPSU} modifiers don’t apply, there’s a good likelihood that your service should not be unbundled, Vanderbilt said. That means that instead of two CPT^® codes, you should only report one.

Tip 3: Append Modifier 58 for Staged Procedures

Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) is another commonly misused modifier.

The provider’s documentation should include identification of each stage of the surgery and plans for returning the patient to the operating room (OR) for additional procedures to manage the patient’s condition, according to Vanderbilt.

Burn care, urology surgeries/care, and spine surgeries are common types of stages surgeries.

Also, sometimes the procedure itself may be so extensive that the patient cannot handle being under anesthesia for that length of time, so it is more appropriate to have them undergo different sessions of the surgery, Vanderbilt added.

Some reasons for a staged procedure include the following: