Modifiers for distinct procedural services

Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.

From the January/February 2015 edition of AOA Focus, page 55.

The Centers for Medicare and Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, a modifier used to define a "distinct procedural service." According to 2013 Comprehensive Error Rate Testing Report data, a projected error of $320 million in payments was made on lines with modifier -59. Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Because it can be so broadly applied, some providers incorrectly consider it to be the "modifier to use to bypass National Correct Coding Initiative (NCCI)."

The NCCI has Procedure to Procedure (PTP) edits to prevent unbundling and consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code, so it would be inappropriate to report it separately. Separate reporting would trigger a separate payment and would constitute double billing. However, it is recognized that in specific limited circumstances the duplicate payment could be sufficiently small or would not exist, so that separate payment would be indicated. Modifiers are used to bypass edits when they are set by NCCI as optional edits.

The primary issue associated with the -59 modifier error rate is that it is defined for use in a wide variety of circumstances, such as a use to identify different encounters, different anatomic sites and distinct services. CMS believes that more precise coding options coupled with increased education and selective editing are needed to reduce the errors associated with this overpayment.

CMS has defined four new HCPCS modifiers—collectively referred to as -X{EPSU} modifiers—to selectively identify subsets of distinct procedural services (-59 modifier) as follows:

• XE Separate Encounter: A service that is distinct because it occurred during a separate encountes
• 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 Nonoverlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

Current Procedural Terminology instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may require a more specific -X{EPSU} modifier for billing certain codes at high risk for incorrect billing.

There is continued confusion on billing fundus photography and Scanning Computerized Ophthalmic Diagnostic Imaging on the same date of service on the same eye. They remain considered "mutually exclusive" according to the current NCCI. Mutually exclusive is defined as "procedures that cannot reasonably be performed at the same anatomic site or same patient encounter." There has been no reliable document defining what these situations are and, therefore, no official guidance can be projected for justification. We recommend that doctors do not unbundle them unless their Medicare contractor specifies that it is allowed.