When you have distinct, separate procedures, know which modifiers will get the claim paid in full.
Modifier 59 Distinct procedural service acts as a “universal unbundling” modifier for procedures that are normally included as part of another procedure, or “bundled.” The modifier tells the payer that there are special circumstances that warrant separate reporting (and payment) of the unbundled code.
Special circumstances that generally warrant modifier 59 include,
The procedures were performed at separate encounters on the same day.
The procedures were performed during the same encounter on separate anatomic organ systems or body sites, incisions, excisions, lesions, or injuries.
The procedures were timed and performed sequentially.
The diagnostic procedure preceded and was the basis for a therapeutic procedure.
An unplanned diagnostic procedure occurred subsequent to the therapeutic procedure.
Be Accurate, Avoid Denials,Because claims are processed without the physician’s documentation, payers rely on the information sent to them to be accurate and assume there is documentation backing it up. Unfortunately, modifier 59 gets misused a lot. As a result, some payers now automatically deny CPT codes appended with modifier 59.
This forces the provider to appeal the denial and send in the documentation to show that modifier 59 was applied correctly. This denial and appeal process is costly for both the provider and the payer — it delays payment and forces the provider’s staff to write appeals and the payer’s staff to read documentation and process appeals.
New Modifiers Replace Modifier 59
The Centers for Medicare & Medicaid Services (CMS) created four new modifiers, referred to as X[ESPU], to better differentiate between the reasons for unbundling codes,
- XE Separate encounter
- XS Separate structure
- XP Separate practitioner
- XU Unusual non-overlapping service
These modifiers apply to Medicare Part B. Some commercial insurance companies have indicated in their online reimbursement manuals they will process the X[ESPU] modifiers, as well, such as Horizon Blue Cross Blue Shield of New Jersey.
CMS does not require providers to use modifiers X[ESPU] in place of modifier 59, and they continue to accept modifier 59, for now. However, if your practice ignores the modifiers which carry more specific information and uses modifier 59 instead, do not be surprised if your Part B carrier audits your modifier 59 usage to make sure it’s not being over-utilized to unbundle CPT codes. Be sure to review the documentation and ask yourself if the unbundling is justified enough to apply the appropriate X[ESPU] modifier.
Let’s see at few examples of when each of the “X” modifiers are used.
This modifier tells the payer that the service is distinct because it occurred during a separate encounter on the same date of service as the bundled procedure.
The patient sees the otolaryngologist in the morning, at which time the doctor performs an evaluation and management (E/M). During the visit, the patient complains of nasal congestion and headaches and the doctor performs a diagnostic nasal endoscopy. The visit is coded,
99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. -Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
That evening, the patient experiences a severe nosebleed and goes to the emergency room (ER). The ER physician is unable to stop the bleeding and calls the otolaryngologist in. The otolaryngologist comes to the ER and performs an extensive control of the nasal hemorrhage with packing. This encounter in the ER for the otolaryngologist is coded,
30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
CPT 30903 is a National Correct Coding Initiative (NCCI) Column 2 code for 31231, meaning the two codes are bundled and not separately payable. Appending modifier XE to 30903 tells the payer that the procedure performed in the ER was a separate encounter from the diagnostic nasal endoscopy performed that same day in the office.
This modifier tells the payer the procedure is distinct because it was performed on a separate organ or structure than the bundled procedure.
The patient arrives at an orthopedist for a knee injection with ultrasound guidance on the left knee and an aspiration of the right knee without ultrasound guidance.
20611-LT Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting -Left side
20610-XS-RT Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance -Right side
20610 is a Column 2 code for 20611. Modifiers LT and RT seem to be enough, telling the payer that the two procedures were performed on two different sides, but not all payers allow modifiers LT and RT to break a bundle. Modifier XS or modifier 59 is needed to break the bundle.
This modifier tells the payer that the service is distinct from the bundled service because it was performed by a different practitioner.
A colorectal surgeon performs 44147 Colectomy, partial; abdominal and transanal approach while another surgeon in the group performs +38747 Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure). CPT +38747 is a Column 2 code of 44147, but since a different physician performed this procedure, modifier XP is used to break the bundle. Coding is: 44147, 38747-XP.Modifier XU
This modifier tells the payer that the service is distinct because it does not overlap usual components of the main service.
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.
A nasal endoscopy and flexible laryngoscopy are not usually both coded and charged during the same encounter because the same scope can be used for both diagnostic procedures.
31231-XU Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31575 Laryngoscopy, flexible; diagnostic
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, and should be listed first.