Radiology Coding Alert

Apply these measures, confidently code X{EPSU} in their respective scenarios.

Despite the fact that they have been in circulation for quite some time now, coders and providers alike are still struggling to grasp the coding fundamentals behind the new set of X{EPSU} modifiers. While they are not exactly taking the place of modifier 59 (Distinct procedural service), the general rule is to consider these four options before resorting to modifier 59 for Medicare and Medicare Advantage Plan patients.

The problem is, there's still a great deal of ambiguity as to what scenarios coders should utilize a given modifier. The radiology specialty, in particular, offers some unique situations that coders of other specialties may not find themselves in.

Starting with the basics and delving into more complex cases, keep reading further to get a firm handle on when, where, and how to implement the X{EPSU} modifiers in your radiology practice.

What to Know About X{EPSU} Modifiers

The X{EPSU} modifiers are as follows:

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

While CMS suggests the use of these four modifiers when the circumstances call for it, Medicare has not outright abolished the use of modifier 59. In coming out with these new modifiers, Medicare explains that "CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT®) instructions state that the -59 modifier should not be used when a more descriptive modifier is available."

Keep in mind: These modifiers are only eligible for patients with Medicare Part B or Medicare Advantage Plans.

Outline a Scenario for Each Modifier

The best way to explain how and when to implement modifiers is to present a scenario in which each could be used. Take a look at these two examples, focusing on the XE and XU modifiers, for a clear understanding of when and where to implement them. Look out for examples of the XS and XP modifiers in next month's issue.

Example 1: A patient presents for a scheduled single view chest X-ray earlier in the day. The following evening the patient returns for a two-view chest X-ray.

A simple Correct Coding Initiative (CCI) edit check reveals that these two procedures are not billable together without the use of an unbundling modifier. After determining that 71045 (Radiologic examination, chest; single view) is the column 2 code, you will then apply the separate encounter modifier as follows:

• 71046 – Radiologic examination, chest; 2 views
• 71045-XE

Example 2: A patient presents for an MRI of the brain with and without contrast followed by a magnetic resonance angiography (MRA) of the head with and without contrast

This is one of those common examples in which you'd traditionally apply modifier 59 due to a CCI edit. Without a modifier, these two procedures are bundled together according to CCI. However, since the MRA exclusively focuses on imaging of the vessels of the brain, these two exams would qualify as "unusual, non-overlapping services." Therefore, you would apply the XU modifier to the column two code.

• 70553 – Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences 
• 70546-XU – Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

Disclaimer: Medicare guidelines have been intentionally vague on the use of these four unbundling modifiers. For any instances in which you are uncertain of which of the four modifiers to apply, you should not hesitate to fall back on modifier 59 until Medicare comes out with definitive rules following the X{EPSU} modifiers.

"Until CMS clarifies further, you may still consider modifier 59 in place of the X{EPSU} modifiers when the situation is unclear," says Leslie Johnson, CPC, Coding Consultant from Flagler Beach, Florida. Until they state otherwise, Medicare will accept either/or option as a correct method of coding," Johnson explains.