CMS Guidance
Pursuant to CMS Manual System, Pub 100-20 One-Time Notification, Transmittal 1422, Effective January 1, 2015 (available at
www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R1422OTN.pdf), "CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows: XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter. … These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. 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."
Scenario Response
• A diagnostic breast ultrasound (CPT 76642) and an ultrasound guided biopsy (CPT 19083) were performed on the same date of service but at different sessions for a patient.
• The provider billed CPT 76642 and CPT 19083, which was modified with "XE."
• Modifier "XE" was used to indicate separate (distinct) procedure for CPT 19083 because the procedures were performed at different times (sessions).
• Historically, modifier 59 is used to indicate a distinct procedural service.
• Effective January 1, 2015, CMS regulations brought forth four new modifiers to give more specification to modifier 59 (distinct procedural service). One of those new modifiers XE is defined as "a service that is distinct because it occurred during a separate encounter."
• Indicators used for conclusion:
- The description of the procedures performed.
- Two separate procedures were performed at different sessions on the same date. (Breast ultrasound was performed but not at the same time as the breast biopsy, which used ultrasound guidance.)
- A modifier is necessary to indicate the procedures were performed on the same date but separately.
- Modifier 59 indicates a separate procedure.
- CMS regulations indicate modifier XE gives a more specific description of modifier 59.
Conclusion
Based upon the above indicators, it appears it is appropriate to bill the following:
• CPT 76642: Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed (limited);
• with CPT 19083: Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous, first lesion, including ultrasound guidance; and
• modified with XE: Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.
— Rolando Russell, MBA, RHIA, CPC, is program director, MBC, at Ultimate Medical Academy.
Follow-Up Question:
I wanted to ask for additional clarification as I re-review the 2018 CMS National Correct Coding Initiative (NCCI) guidelines.
The 2018 NCCI policy manual states the following:
"9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service
may be reported separately
if the two procedures are performed in different anatomic regions. For example, a physician
may report a diagnostic ultrasound CPT code and CPT code 76942 (Ultrasonic guidance for needle placement ...) when performed in
different anatomic regions on the same date of service. Physicians should not avoid edits
based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service."
If the decision point isn't separate encounters or separate times of the day but rather services must be of "different anatomic regions" on the same date of service, then would we not be able to bill in our scenario? The content above in italics represents changes in the guidelines for 2018. I believe in 2017 it didn't matter if it was a separate region; you couldn't bill a diagnostics ultrasound of any region with an ultrasound-guided procedure on the same date of service. Would it matter in our scenario that CPT 76642 was performed later than 19083 was performed with regards to the guidelines above?
A CPC at a New England hospital
Response:
I still think you can bill as you have.
This is what I see: You're focusing on this part of the NCCI policy: "evaluation of an anatomic region and guidance for a needle placement procedure."
The NCCI references CPT code 76942: Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
It makes sense that you can't bill for guidance when doing an ultrasound because that's part of the procedure.
This code is for guidance only. That's not what you're billing for.
Your code, 76642, is for the actual breast ultrasound, which it appears is performed on the patient first. Then it seems they perform a breast biopsy, CPT 19083, probably because of something seen on the ultrasound. CPT 19083 includes ultrasound guidance done at the time of biopsy.
Therefore, I don't think you have to worry because you're not actually trying to bill the "ultrasound guidance" alone.
— Rolando Russell, MBA, RHIA, CPC