Radiology Coding Alert

See an instance where more than one modifier fits.

Most seasoned radiology coders know how to unbundle a set of two or more CPT^® codes that yield a National Correct Coding Initiative (NCCI) edit of “1.” However, it’s not necessarily the “how” you should be concerned about — it’s the “when.”

Your first point of order should be to familiarize yourself with Chapter IX of the NCCI Policy Manual. On top of that, you’ve got to understand which of the correct X{EPSU} modifiers to report, when appropriate.

Read on for a refresher on when and how to use these modifiers, and check out two examples that will put what you’ve learned to the test.

Remember 59 and X{EPSU} Basics

Frequent modifier 59 (Distinct procedural service) misuse propelled CMS in 2015 to create the following four new, more-precise modifier options, known as the X{EPSU} modifiers, for reporting distinct service claims:

• XE (Separate encounter…) describes a service that is distinct because it occurred during a different patient encounter.
• XP (Separate practitioner…) describes a service that is distinct because it was performed by a different healthcare provider.
• XS (Separate structure…) describes a service that is distinct because it was performed on a different anatomic site.
• XU (Unusual non-overlapping service…) describes a service that is distinct because it does not overlap with the usual components of the main service.

Avoid: You should never use 59 and one of the X{EPSU} modifiers together for the same claim, because they’re redundant. The X{EPSU} modifiers describe a specific subset of circumstances that would warrant using modifier 59.

Key: “Before immediately appending modifier 59, always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It is extremely important to use the X{EPSU} modifiers accordingly.”

Outline Key Differences, Similarities Between XS, XU

Example: A computed tomography (CT) abdomen and pelvis, with and without contrast, performed on the same day as a computed tomography angiography (CTA) abdomen and pelvis.

You might think that these are overlapping anatomic sites, but the radiologist is in fact imaging two distinct portions of the abdomen and pelvis with each respective scan. You will report code 74178 (Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions) for CT imaging of organs native to the abdomen and pelvis.

On the other hand, you’ll report code 74174 (Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing) for the CTA imaging of the native vessels of the abdomen and pelvis. This may involve visualization of the abdominal aorta, internal/external iliac arteries, and the celiac, splenic, and renal arteries.

An NCCI edits check will confirm an edit between 74174 and 74178 with a modifier “1” indicator. For non-Medicare payers, you should first confirm that the X{EPSU} modifiers are eligible to be reported on the category 2 code (74178). If allowed, you’ll see that you’ve actually got the option to choose between modifier XS or XU. There’s an argument to be made for both, but ultimately either is correct with respect to this clinical encounter. Modifier XS is technically correct since the abdominal and pelvis vascular system is a different anatomic site from that of the respective organs it’s surrounding. Modifier XU also fits the bill as an unusual non-overlapping service since there is no imaging overlap between the vessels and the organs. In other words, the radiologist will not be able to gather the same radiological impression of a specific abdominal or pelvic organ when reviewing the CTA scan imaging. The alternative is also true with the CT scan imaging.

Use NCCI Policy Manual to Your Advantage

Example: A bilateral screening and diagnostic mammogram are performed by the same radiologist on the same day.

The NCCI edit between 77066 (Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral) and 77067 (Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed) shows you’ve got a modifier indicator “1,” with 77067 designated as the column 2 code. However, you’ve got more than one modifier consideration to take into account with this example.

First, you’ve got to remember to append modifier GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to the diagnostic mammography (77066) when performed on the same day as a screening mammography. The next step requires you to make sure you’ve got access to the 2020 NCCI Policy Manual. Adhering to guidelines from the 2019 NCCI Policy Manual or prior will offer different instructions on modifier usage.

In the 2020 NCCI Policy Manual (Chapter IX), you’ll encounter guidelines and coding instruction for a variety of radiological services. In fact, you’ll find specific guidance on how to append modifiers on claims that include same-day diagnostic and screening mammograms. In addition to modifier GG, the NCCI Policy Manual instructs that you append modifier 59 or XU. You’ll find that the 2019 version and prior included modifier 59, exclusively. While either option is technically correct, modifier XU providers additional detail to the payer as to the reason for the same day services. Assuming your non-Medicare payers accept the X{EPSU}, you should append 77067 with modifier XU in applicable instances.

Resource: To view the current NCCI Policy Manual, go to www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index?edirect=/NationalCorrectCodiNitEd/01_overview.asp, scroll to the bottom of the page, and click on the link.