The Centers for Medicare and Medicaid Services acknowledges that there are code combinations that may warrant an exception in reporting based on clinical documentation.
Coders tend to err on the side of caution when reviewing the NCCI edits or they don't understand "when" modifiers should be appended to the CPT code to indicate a "separate" and "distinct" procedure that would otherwise be considered bundled. In this instance, the coder's knowledge of the procedure(s) and understanding the rationale behind the NCCI edits will assist in determining whether a modifier is applicable.
One of the most incorrectly reported modifiers is the -59 modifier (distinct procedural service). Only under certain circumstances should the -59 modifier be applied. The overuse and misuse of the -59 modifier has been a red flag to Medicare and the OIG to the point that Medicare has now established four new modifiers that will go into effect Jan. 1, 2015,
Per the CMS Transmittal 1422, "……each modifier is based on a specific aspect of the unbundled procedure — when the procedures took place, the anatomical locations where they were performed, who performed the services or what made the second service unusual:
1. XE (Separate encounter, a service that is distinct because it occurred during a separate encounter).
2. XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure).
3. XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner).
4. XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)."
CMS transmittal 1422 explains that there may be instances when modifier 59 is still reported, but it should not be reported when a more specific modifier is available.
As always, please refer to current CMS transmittals, LCD/NCD directives as well as carrier specific reporting guidelines prior to implementation of any modifier reporting changes. For more in-depth information regarding these four new modifiers, please refer to CMS Transmittal 1422 at:
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
More articles on ASC issues:
CMS: 3 new ICD-10 testing weeks
4 ASCs with effective purchasing strategies
7 things for ASC leaders to know for Thursday
Coders tend to err on the side of caution when reviewing the NCCI edits or they don't understand "when" modifiers should be appended to the CPT code to indicate a "separate" and "distinct" procedure that would otherwise be considered bundled. In this instance, the coder's knowledge of the procedure(s) and understanding the rationale behind the NCCI edits will assist in determining whether a modifier is applicable.
One of the most incorrectly reported modifiers is the -59 modifier (distinct procedural service). Only under certain circumstances should the -59 modifier be applied. The overuse and misuse of the -59 modifier has been a red flag to Medicare and the OIG to the point that Medicare has now established four new modifiers that will go into effect Jan. 1, 2015,
Per the CMS Transmittal 1422, "……each modifier is based on a specific aspect of the unbundled procedure — when the procedures took place, the anatomical locations where they were performed, who performed the services or what made the second service unusual:
1. XE (Separate encounter, a service that is distinct because it occurred during a separate encounter).
2. XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure).
3. XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner).
4. XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)."
CMS transmittal 1422 explains that there may be instances when modifier 59 is still reported, but it should not be reported when a more specific modifier is available.
As always, please refer to current CMS transmittals, LCD/NCD directives as well as carrier specific reporting guidelines prior to implementation of any modifier reporting changes. For more in-depth information regarding these four new modifiers, please refer to CMS Transmittal 1422 at:
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
More articles on ASC issues:
CMS: 3 new ICD-10 testing weeks
4 ASCs with effective purchasing strategies
7 things for ASC leaders to know for Thursday