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Modifier 59 changes-New CMS Claims Processing Logic- Example


The modification to the claims processing logic for modifiers 59, XE, XS, XP, and XU.
These modifiers were being processed only when applied to the Column 2 code in a bundled pair, per NCCI, with a modifier indicator “1.” This meant if the separate procedure modifier was appended on the Column 1 code, the modifier would not override the edit and the system would reject the code.
CMS carriers will now process the separate procedure modifier when it’s used on either the Column 1 procedure or the Column 2 procedure, effective July 1, 2019.
The NCCI bundling edit will be bypassed when modifier 59, XE, XS, XP, or XU is used on either the Column 1 code or Column 2 code.
Does this make a difference???
There were separate procedure modifier edit bypasses being ignored when appended to the Column 1 code. This required a corrected claim to be resubmitted for reprocessing and caused additional cost to both the provider and the carrier.
Why are separate procedure modifiers being put on Column 1 codes to get an edit bypassed?
This usually happens when the Column 1 code carries less RVUs than the Column 2 code, as described in the below example.
As a result, the Column 2 code appears before the Column 1 code on the claim because CPT codes are placed in RVU order to minimize the effects of multiple procedure discounts taken by the payer.
Placing a separate procedure modifier on the first of the two codes bundled on the claims appears awkward and, as a result, the biller tends to put modifier 59, XE, XS, XP, or XU on the bundled CPT appearing lower in the claim.
The new instruction allows a more billing-friendly approach for applying the separate procedure modifier.
Current NCCI Edits Example:
The otolaryngologist performs a rigid diagnostic nasal endoscopy for nasal complaints, and then pulls out the rigid endoscope and performs a flexible laryngoscopy to evaluate the patient’s complaints of coughing, throat clearing, and difficulty swallowing.
31231-XU            Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) (Column 2 codes but High RVU 5.69)
31575     Laryngoscopy, flexible; diagnostic) (Column 1 codes but Low RVU 3.31)
CPT 31231 is coded whether a rigid endoscope or a flexible endoscope is used, and it’s a Column 2 code of 31575. Interestingly, 31231 has more relative value units (RVUs) than 31575, but it should be listed first.
With this guidance, the mentioned above example should be billed on the claim as follows (consistent with the RVUs), Effective July 1,2019
 31231            Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31575 - XU    Laryngoscopy, flexible; diagnostic)



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