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Tag Archives: Modifier

Waive Cost Sharing on Applicable Claims Using Modifier CS

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The implementation of the Families First Coronavirus Response Act waives cost-sharing (coinsurance and deductibles) for COVID-19 testing-related services.  The Act is a bit convoluted (as most Acts are) so the Centers for Medicare & Medicaid Services (CMS) breaks down what it all means for Medicare Part B claims in a special edition of MLN Connects, released […]

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Modifier 59 Is Over-Used and Abused, MAC Says

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Failure to adopt the X[ESPU] modifiers may be putting your practice at risk for Medicare fraud. Modifier 59 Distinct procedural service continues to be the most-used modifier among Medicare Part B providers, according to Novitas, and it is sending up red flags for possible Medicare fraud and abuse. Representatives from the Medicare Administrative Contractor (MAC) […]

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$1.85 Million Paid to Settle Urology Modifier 25 Whistleblower Case

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Separately asking routine evaluation and management (E/M) services provided on a similar day as another procedure is usually denied by Medicare. Care providers might typically individually bill E/M services if they meet certain criteria and append modifier 25 vital, on an individual basis specifiable analysis and management service by a similar MD or different qualified health care skilled on a similar day of the procedure or different service to the claim. Modifier twenty five shows payers, like Medicare, that a care supplier went higher than and on the far side the standard E/M of pre-operative and post-operative care related to the medical procedure; which it had been vital, on an individual basis specifiable service. If this modifier gets used, a supplier unbundles a service and receives further compensation ― overpayments of Medicare bucks. Per a whistleblower, this is what Skyline urology allegedly did between January. 1, 2013 and Dec. 31, 2016.

Read the Full Story here!

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The Coding Network

New CLIA Waived Tests – Modifier QW not Required List effective from October 1, 2019

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CR 11354 informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify the MACs of the new tests so that they can accurately process claims. Make sure your billing staffs are aware of these CLIA-related changes.

CR 11354 presents the latest tests approved by the FDA as waived tests under CLIA. 
The Current Procedural Terminology (CPT) codes for these new tests must have the modifier “QW” to be recognized as a waived test. 

The tests mentioned on the first page of the list attached to CR 11354,do not require a “QW” modifier to be recognized as a waived test. The CPT codes are,

81002 URINALYSIS NONAUTO W/O SCOPE
81025 URINE PREGNANCY TEST
82270 OCCULT BLOOD FECES
82272 OCCULT BLD FECES 1-3 TESTS
82962 GLUCOSE BLOOD TEST
83026 HEMOGLOBIN COPPER SULFATE
84830 OVULATION TESTS
85013 SPUN MICROHEMATOCRIT
85651 RBC SED RATE NONAUTOMATED

The CPT code, effective date, and description for the latest tests approved by the FDA as waived tests under CLIA include,

80305QW, December 13, 2018, Shenzhen Bioeasy Biotechnology Co., Ltd, BIOEASY Multi-Drug Test Cup
80305QW, April 18, 2019, Mercedes Scientific Inc., Platinum+ Multi-Drug Urine Test Cup
80305QW, April 18, 2019, Mercedes Scientific Inc., Platinum+ Multi-Drug Urine Test Dip Card
87880QW, May 9, 2019, McKesson Consult Strep A Test Cassette
87502QW, May 28, 2019, Alere ID NOW Instrument {Nasal and Nasopharyngeal swabs}, for Influenza A/B
87634QW, May 29, 2019, Alere ID NOW Instrument {Nasopharyngeal swabs}, for respiratory syncytial virus


Source: New Waived Tests


Coding Ahead

Proper Use of Modifier 50

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Novitas Solutions recently released a Modifier 50 Fact Sheet. It’s reminding to medical coders of the proper use for this CPT payment modifier. 

The Medicare Administrative Contractor (MAC) for Jurisdictions H and L warns that, effective for Part B claims received on and after Aug. 16, 2019, services will be rejected as unprocessable when modifier 50 Bilateral procedure is used inappropriately. 

When is the right time to append modifier 50? 
  • Modifier 50 may be appropriate if the bilateral indicator is 1 or 3. 
  • Do not append modifier 50 to a code with a bilateral surgery indicator of 0, 2 or 9. 

Inappropriate Use: 

  • Inappropriate to apply to a “bilateral description” code.
  • Do not append to procedures for midline organs such as the bladder, uterus, esophagus or nasal septum.
  • Inappropriate to report when performed on different areas of same side of body.
  • Modifier 50 cannot be appended when bilateral indicators are 0, 2, or 9. 

Example: 

 The terminology for procedure code 27158 (osteotomy, pelvis, bilateral) indicates the procedure is performed bilaterally. Therefore, it’s not appropriate to report modifier 50 with this procedure code. 

Bilateral Surgery indicators:

“0″ indicates a unilateral code; Modifier 50 is not billable. 
“1” indicates modifier 50 can be appropriate. 
“2” indicates a bilateral code; modifier 50 is not billable. 
“3” indicates primary radiology codes; modifier 50 is billable.
“9” indicates that the concept does not apply. (office visit) 

Click Here to verify the B/L modifier Indicator 

Additional Information: 

Don’t Report Modifiers 50 and 78 Together, 

  • If a (subsequent) bilateral procedure requires a return to the operating room after the initial surgery, and the bilateral indicator in the MPFSDB is 1 or 2, do not submit CPT modifier 50. 
  • CPT modifiers 50 and 78 cannot be submitted for the same service. Instead, submit the surgery procedure code with CPT modifier 78 and HCPCS modifier RT on one line, and submit the same surgery procedure code with CPT modifier 78 and HCPCS modifier LT on a separate detail line.

Source: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00144531 



Coding Ahead

Proper Usage of Modifier 59

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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.

Modifier XE

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.

Example:

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.

Modifier XS

This modifier tells the payer the procedure is distinct because it was performed on a separate organ or structure than the bundled procedure.

Example:

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.

Modifier XP

This modifier tells the payer that the service is distinct from the bundled service because it was performed by a different practitioner.

Example:

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.

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.

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.


Coding Ahead

Modifier 59 changes-New CMS Claims Processing Logic- Example

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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)




Coding Ahead

MAC Clarifies Modifier 50 Appropriate Use

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Novitas Solutions recently issued a Modifier 50 Fact Sheet, reminding medical coders of the proper use for this CPT payment modifier. The Medicare Administrative Contractor (MAC) for jurisdictions H and L warns that, effective for Part B claims received on and after Aug. 16, 2019, services will be rejected as unprocessable when modifier 50 Bilateral […]

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AAPC Knowledge Center

Modifier 59 Changes in PTP edits

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Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes.

Modifiers 59, XE, XS, XP, and XU are among the NCCI-associated modifiers. The Multi-Carrier System (MCS) currently requires that modifiers 59, XE, XS, XP, or XU be appended to the column two code of a PTP edit to bypass the edit. With the implementation of CR 11168,

“Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit”.

Source: Modifier 59 Changes in PTP edits


Coding Ahead

Change to RT and LT Modifier Use

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The Durable Medical Equipment Medicare Administrative Contractors (DME MAC) are changing the requirement that medical coders to use the right (RT) and left (LT) modifiers for certain HCPCS codes, and that the modifiers be used when billing two of the same item or accessory on the same date of service and the items are being […]

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