Coding Corner
How Best to Use Modifier 59 Jonathan Rubenstein, MD Chesapeake Urology Associates, Baltimore, MD
[Rev Urol. 2015;17(1):33-34 doi: 10.3909/riu0657]
®
© 2015 MedReviews , LLC
T
he National Correct Coding Initiative (NCCI) maintains a list of procedures that are “bundled” and therefore cannot be billed at the same date and time. In some circumstances the two procedures can never be paid with one another under any circumstance, whereas in other cases the two procedures can be paid together if certain unique circumstances exist. Modifiers are used to help communicate these unique circumstances and are necessary to bypass the NCCI edits. Commonly used modifiers to communicate these unique circumstances include Modifier 58 (staged procedure within the global period), Modifier 59 (distinct procedural service), Modifier 76 (repeat procedure), Modifier 78 (subsequent or related procedure/ service within a global, unplanned return to the operating room), and Modifier 79 (unrelated procedure/service by the same provider within the global period). Modifier 59 is an important modifier used for a variety of circumstances; however, it is often thought to be applied incorrectly to bypass the NCCI edits. To reduce the error rate, on August 15, 2014, the Center for Medicare and Medicaid Services released Change Request 8863, which established four new subsets of Healthcare Common Procedure Coding System modifiers to define subsets of Modifier 59 (distinct procedural service), with an implementation date of January 5, 2015 (http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM8863.pdf). The four new modifiers are as follows: XE: Separate Encounter, 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.) XS: Separate Structure, a service that is distinct because it was performed on a separate organ/structure. XP: Separate Practitioner, a service that is distinct because it was performed by a different practitioner. XU: Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service. With these four new modifiers/subsets of Modifier 59, how do we best use them in 2015 and beyond, and does this help us understand what is billable together under certain circumstances and what is not? On one hand, these four new modifiers/subsets of Modifier 59 help us to better define how to properly use Modifier 59; on the other hand, they may also create confusion. The exact use of these modifiers remains undefined, as ultimately the use of any modifier remains the decision of the individual contractor’s interpretation. Not all contractors have yet stated if or when these new modifiers will Vol. 17 No. 1 • 2015 • Reviews in Urology • 33
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How Best to Use Modifier 59 continued be used; in addition, Modifier 59 was not eliminated and may still be used. Furthermore, several contractors had previously instructed their members to use or consider using Modifier 76 in many or all situations in lieu of Modifier 59 due to the aforementioned difficulties with Modifier 59, including Noridian Healthcare Solutions (www.noridianmedicare.com/partb/claims/ alerts/082313.html), WPS Medicare Health Insurance (www.wpsmedicare.com/j5macpartb/resources/ mod i f iers/mod i f iers59a nd76 . shtml), and Cahaba Government Benefit Administrators (http:// w w w. c a h a b a g b a . c o m / n e w s / changes-to-modifier-59-importantnotice/). Even more confusing is that the WPS Web site indicates that Modifier 76 should not be used on surgical procedure codes.
Definitions
Modifier 59 describes a distinct procedural service, and is used to identify procedures and services that are not normally reported together. For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury. Modifier 59 should not be used on Evaluation and Management Codes, and should only be used when no other modifier is accurate. Although it does not require a different diagnosis for each coded procedure, a different diagnosis also does not necessarily justify the use of the modifier. Modifier 59 should not be used (as it is unnecessary) if the narrative description of the two codes is different. Modifier 59 is used appropriately for two services
described by timed codes provided during the same encounter only when they are performed sequentially. Modifier 59 can be used if a diagnostic procedure becomes the basis for performing a therapeutic procedure, if the information obtained clearly provides the information to perform the procedure, but should not be used if the diagnostic procedure is part of the therapeutic procedure, or constitutes complexity of the procedure. Examples of Proper Urologic Use Modifier 59 or the XS modifier may be used appropriately for procedures performed on different anatomic sites during the same encounter when the procedures are performed on different organs or on different, noncontiguous lesions in the same organ. For example, a proper use may be when a surgeon performs a laparoscopic partial nephrectomy (CPT 52343) on two separate, noncontiguous lesions in the same kidney. In contrast, CPT 50542 is defined as laparoscopic ablation of renal mass lesion(s); therefore the use of a 59 or XS modifier is not appropriate when ablating more than one lesion. As intraoperative guidance and monitoring when performed is part of the description of CPT 50542, it should not be separately reported or billed. However, if ultrasound guidance is used to biopsy a separate lesion, consider using CPT 76942, “Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation” with Modifier 59, or the XP modifier if unrelated to the laparoscopic kidney tumor ablation. Instillation of an antineoplastic agent (CPT 51740) such as
mitomycin is bundled to most cystoscopic procedures, including bladder tumor treatments. If the antineoplastic agent is instilled intraoperatively, two codes should not be billed. However, if both procedures are performed on the same date but at different encounters, they should be separately billable. For example, if a patient undergoes a transurethral resection of a medium-sized bladder tumor (CPT 52235) in an ambulatory setting, is discharged, then goes to the office for the instillation of the antineoplastic agent, it is appropriate to bill CPT 51740 with an XE modifier. For treatment of kidney stones, the new modifiers may help clear up some confusion. The kidney and the ureter are separate structures, so Modifier 59 (or the XS modifier) may be appropriately used when ureteroscopy and laser lithotripsy are performed on separate, noncontiguous stones in the ureter and kidney on the same side at the same session. Some argue that stones are lesions and therefore multiple, noncontiguous stones in the ureter, or multiple noncontiguous stones in the kidney, may fit the definition of proper use of Modifier 59 or XS, whereas others argue that they are not lesions. In these cases, local payor rules should be followed.
Conclusions
Although there is not yet any specific consensus on their use, the four new Modifiers may help define distinct billable or repeat services. However, it is important to check with your own local carrier for their rules with regard to which modifiers they accept and under which circumstances. As always, bills should only be submitted for legitimately billable services.
34 • Vol. 17 No. 1 • 2015 • Reviews in Urology
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How Best to Use Modifier 59 Jonathan Rubenstein, MD Chesapeake Urology Associates, Baltimore, MD
[Rev Urol. 2015;17(1):33-34 doi: 10.3909/riu0657]
®
© 2015 MedReviews , LLC
T
he National Correct Coding Initiative (NCCI) maintains a list of procedures that are “bundled” and therefore cannot be billed at the same date and time. In some circumstances the two procedures can never be paid with one another under any circumstance, whereas in other cases the two procedures can be paid together if certain unique circumstances exist. Modifiers are used to help communicate these unique circumstances and are necessary to bypass the NCCI edits. Commonly used modifiers to communicate these unique circumstances include Modifier 58 (staged procedure within the global period), Modifier 59 (distinct procedural service), Modifier 76 (repeat procedure), Modifier 78 (subsequent or related procedure/ service within a global, unplanned return to the operating room), and Modifier 79 (unrelated procedure/service by the same provider within the global period). Modifier 59 is an important modifier used for a variety of circumstances; however, it is often thought to be applied incorrectly to bypass the NCCI edits. To reduce the error rate, on August 15, 2014, the Center for Medicare and Medicaid Services released Change Request 8863, which established four new subsets of Healthcare Common Procedure Coding System modifiers to define subsets of Modifier 59 (distinct procedural service), with an implementation date of January 5, 2015 (http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM8863.pdf). The four new modifiers are as follows: XE: Separate Encounter, 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.) XS: Separate Structure, a service that is distinct because it was performed on a separate organ/structure. XP: Separate Practitioner, a service that is distinct because it was performed by a different practitioner. XU: Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service. With these four new modifiers/subsets of Modifier 59, how do we best use them in 2015 and beyond, and does this help us understand what is billable together under certain circumstances and what is not? On one hand, these four new modifiers/subsets of Modifier 59 help us to better define how to properly use Modifier 59; on the other hand, they may also create confusion. The exact use of these modifiers remains undefined, as ultimately the use of any modifier remains the decision of the individual contractor’s interpretation. Not all contractors have yet stated if or when these new modifiers will Vol. 17 No. 1 • 2015 • Reviews in Urology • 33
4004170006_RIU0657.indd 33
23/04/15 1:51 PM
How Best to Use Modifier 59 continued be used; in addition, Modifier 59 was not eliminated and may still be used. Furthermore, several contractors had previously instructed their members to use or consider using Modifier 76 in many or all situations in lieu of Modifier 59 due to the aforementioned difficulties with Modifier 59, including Noridian Healthcare Solutions (www.noridianmedicare.com/partb/claims/ alerts/082313.html), WPS Medicare Health Insurance (www.wpsmedicare.com/j5macpartb/resources/ mod i f iers/mod i f iers59a nd76 . shtml), and Cahaba Government Benefit Administrators (http:// w w w. c a h a b a g b a . c o m / n e w s / changes-to-modifier-59-importantnotice/). Even more confusing is that the WPS Web site indicates that Modifier 76 should not be used on surgical procedure codes.
Definitions
Modifier 59 describes a distinct procedural service, and is used to identify procedures and services that are not normally reported together. For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury. Modifier 59 should not be used on Evaluation and Management Codes, and should only be used when no other modifier is accurate. Although it does not require a different diagnosis for each coded procedure, a different diagnosis also does not necessarily justify the use of the modifier. Modifier 59 should not be used (as it is unnecessary) if the narrative description of the two codes is different. Modifier 59 is used appropriately for two services
described by timed codes provided during the same encounter only when they are performed sequentially. Modifier 59 can be used if a diagnostic procedure becomes the basis for performing a therapeutic procedure, if the information obtained clearly provides the information to perform the procedure, but should not be used if the diagnostic procedure is part of the therapeutic procedure, or constitutes complexity of the procedure. Examples of Proper Urologic Use Modifier 59 or the XS modifier may be used appropriately for procedures performed on different anatomic sites during the same encounter when the procedures are performed on different organs or on different, noncontiguous lesions in the same organ. For example, a proper use may be when a surgeon performs a laparoscopic partial nephrectomy (CPT 52343) on two separate, noncontiguous lesions in the same kidney. In contrast, CPT 50542 is defined as laparoscopic ablation of renal mass lesion(s); therefore the use of a 59 or XS modifier is not appropriate when ablating more than one lesion. As intraoperative guidance and monitoring when performed is part of the description of CPT 50542, it should not be separately reported or billed. However, if ultrasound guidance is used to biopsy a separate lesion, consider using CPT 76942, “Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation” with Modifier 59, or the XP modifier if unrelated to the laparoscopic kidney tumor ablation. Instillation of an antineoplastic agent (CPT 51740) such as
mitomycin is bundled to most cystoscopic procedures, including bladder tumor treatments. If the antineoplastic agent is instilled intraoperatively, two codes should not be billed. However, if both procedures are performed on the same date but at different encounters, they should be separately billable. For example, if a patient undergoes a transurethral resection of a medium-sized bladder tumor (CPT 52235) in an ambulatory setting, is discharged, then goes to the office for the instillation of the antineoplastic agent, it is appropriate to bill CPT 51740 with an XE modifier. For treatment of kidney stones, the new modifiers may help clear up some confusion. The kidney and the ureter are separate structures, so Modifier 59 (or the XS modifier) may be appropriately used when ureteroscopy and laser lithotripsy are performed on separate, noncontiguous stones in the ureter and kidney on the same side at the same session. Some argue that stones are lesions and therefore multiple, noncontiguous stones in the ureter, or multiple noncontiguous stones in the kidney, may fit the definition of proper use of Modifier 59 or XS, whereas others argue that they are not lesions. In these cases, local payor rules should be followed.
Conclusions
Although there is not yet any specific consensus on their use, the four new Modifiers may help define distinct billable or repeat services. However, it is important to check with your own local carrier for their rules with regard to which modifiers they accept and under which circumstances. As always, bills should only be submitted for legitimately billable services.
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