Wiki Wound Care and Modifiers - HELP!

[kfrycpc]

Hello,

I am having trouble with coding wound care and modifiers. I am hoping you can help me

The encounters come over with the CPT codes checked off, so all we do is add modifiers and dx codes.

I have a few encounters that are denying and I thought I was adding the correct mods but now I feel totally unsure. Some of the scenarios are:

99213-25
11042-59
97597-59

Is this correct? And if it was Medicare would be the 59 be an XU?

Another one is:

99213-25
11042-XU
97597-XU
15271

Correct? It got paid as such but why wouldn't there be an XU on the 15271??

And lastly:

99213-25
11042-59
97597-59
97598-59

I didn't think the 59 had to be put on the 97598 but we are getting that denial that is has to.

Also, has the XU replaced the 59?

And one last question! When you have 2 CPT codes and you need a 59 mod, does it go on the one with the highest RVU, or if not, how it is decided which code gets the mod?

Thanking you in advance,
Kellie

 

[thomas7331]

In order to determine which code needs the modifier, you'll need to look at the NCCI tables which you can find on the CMS website in the Medicare section under 'Coding'. There are instructions with the tables, but in short, if you find the code pair on the table, and a modifier is supported by documentation, the modifier goes on the code in the second column. It is not always logical, for example as you mention, the 97598 requires the modifier whereas in other cases add-on codes usually do not.

59 is considered a modifier 'of last resort' to be used when no more specific modifier applies but has not been replaced. In the examples you give, I would not recommend XU because that describes an 'unusual' case where the codes need to be reported together. More likely, for wound care, I would think you're billing these codes together because they're performed on different wounds? In that case, I'd use XS for a separate structure, unless your payer has given you guidance to the contrary.

Hope that helps some.

 

[espressoguy]

In your first example, there doesn't need to be a modifier on the 11042.

Second example would be correct assuming the XU is the correct modifier. I am uncertain that it is, but I am also uncertain that XS is any better. I am still using 59 in this situation. Our CMS MAC, Noridian, is not requiring the use of the 'X' modifiers until CMS provides them with further guidelines as to how they are supposed to be used.

In your third example, again there doesn't need to be a modifier on the 11042 or the 97598 add-on.