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The Use and Understanding Of X{EPSU} Modifiers

By | Compliance, Insurance Coding | No Comments

I’ve been getting a lot of questions about the -59 modifier and the new X modifiers, so I thought I would take some time here to explain the use of these modifiers and to let you know why most insurers, including Medicare, still continue to use the -59 modifier.

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.

The -59 modifier is the most commonly used and commonly abused modifier. According to 2013 CERT Report data, incorrect -59 modifier usage amounts to a $77 million per year overpayment.

Because of this, CMS believes that more precise coding options are needed to reduce the errors associated with this overpayment.

As a result, CMS established the following four new HCPCS modifiers, referred to collectively as -X{EPSU} modifiers, to define specific subsets of the -59 modifier:

  • XE – “Separate encounter.” A service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
  • XP – “Separate Practitioner.” A service that is distinct because it was performed by a different practitioner.
  • XS – “Separate Structure.” A service that is distinct because it was performed on a separate anatomical area.
  • XU – “Unusual Non-Overlapping Service.” The use of a service that is distinct because it does not overlap usual components of the main service.

These X{EPSU} modifiers are intended to provide greater reporting specificity.

Though CMS will continue to recognize the -59 modifier, the Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available.
In some instances CMS may selectively require a more specific – X modifier for billing procedures at high risk for incorrect billing.

Because the X modifiers are more specific versions of the -59 modifier, it would be incorrect to include both modifiers on the same line.

Though the use of the new modifiers was scheduled to start January 1, 2015, don’t hold your breath.

Here’s why:

  • Chiropractors are only paid for 98940, 98941 and 98942. None of your adjustment codes would require modifier -59.
  • For now, secondary billing for Medicare is uncertain. Secondary (private) payers haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It’s likely they will adopt the same rule sooner or later, so keep an eye out for changes.
  • To date, private payers are not requiring the new modifiers. Providers such as BCBS, Aetna, and Cigna haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It is likely that they will in the future so watch for updates from private payers.

 

Though it is likely that the -59 Modifier days are numbered, until then continue to code as usual, with modifier -59.

The “Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.

All the Best,
Dr. John Davenport
Chief Compliance Officer

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

In part one of this article we learned that starting January 1st, the American Medical Association implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.

The stated reason for the need to change the Evaluation and Management (E/M) guidelines was that the guidelines did little to support patient care and that the old E/M guidelines consume too much of the physician’s time and didn’t reflect the actual work done by the physician.

While the current E/M code set guidelines use the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill, The new guidelines will allow practitioners to document office and outpatient E/M level codes 99202—99215 based on the total time spent on the date of the encounter or medical decision making (MDM).

Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.

For example, when time is used to select the appropriate level for E/M services codes, the following are the time codes used as a determining factor for each category:

New patient codes:

 Established patient codes:

99202: 15-29 minutes 99212: 10-19 minutes
99203: 30-44 minutes 99213: 20-29 minutes
99204: 45-59 minutes 99214: 30-39 minutes

The E/M services for which these guidelines apply require a face-to-face encounter with the physician and remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

With that said, in the first part of this article we reviewed the descriptors and guidelines that support the use of time to select the appropriate level for E/M services in depth.

If you didn’t read part one of this article, regarding the use of time, read the last newsletter HERE. Knowing this information and the differences should help you in deciding which method would be best for your office.

The purpose of this article is to learn the descriptors and guidelines that support the use of a Medical Decision Making (MDM) E/M code set.

In general, MDM is related to the process of establishing a diagnosis, assessing the status of a condition, and selecting a management option. MDM is defined by the following three elements:

  • The number and complexity of problem(s) addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information reviewed and considered for the date of the encounter and not a subsequent encounter.
  • The risk of complications, morbidity, and/ or mortality of patient management decisions made that are associated with the patient’s problem, diagnostic procedures, treatment and treatment alternatives at the time of the visit.

This includes the possible management options selected after sharing medical decision making and explaining both the risks and benefits of each management option with the patient, family and/or legal representative.

It’s also important to know the four levels of MDM recognized as part of the new 2021 E/M guidelines: straightforward, low, moderate, and high.

To determine the most appropriate level of MDM to report, the physician would review and meet the qualifications for each of the three elements of MDM.

To aid physicians in selecting the level of MDM for reporting the correct E/M service code, the AMA developed a guideline to assist in selecting the acceptable level of MDM.

The following guideline includes the four levels of medical decision making and the three elements of medical decision making.

Note that to qualify for a particular level of medical decision making, at least two of the three elements for that level of medical decision making must be met or exceeded.


Three Element Qualification Guide:

Level of MDM: Straightforward  (99202/99212)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Minimal
      – 1 self-limited or minor problem
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Minimal or none
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Minimal risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Low  (99203/99213)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Low
      2 or more self-limited or minor problems or one or more of the following:

      • 1 stable chronic illness
      • 2 acute, uncomplicated illness or injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Limited (Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

  • Any combination of 2 from the following:
  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*

Category 2: Assessment requiring an independent historian(s)
( An Independent historian is any individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary.)

  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Low risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Moderate  (99204/99214)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Moderate
      • 1 or more chronic illnesses with exacerbation progression, or side effects of treatment or one or more of the following:
        • 2 or more stable chronic illnesses
        • 1 undiagnosed new problem with uncertain prognosis
        • 1 acute illness with systemic symptoms
        • 1 acute complicated injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • (Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:
  • Review of prior external note(s) from each unique source
  • Review of the result(s) of each unique test and ordering of each unique test
  • Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported)

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional or appropriate source (not separately reported)
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health

In review, history exam is no longer a defining element when choosing the appropriate level of medical decision making. But it is important to understand that even though the nature and extent of the history and/or physical examination is determined by the treating physician, the guidelines still require that all E/M services include a medically appropriate history and or physical examination.

Remember that billing for outpatient evaluation and management (E/M) services is based on complexity as documented, and not based on implied or undocumented complexity.

All the Best,

Dr. John Davenport
Chief Compliance Officer

Compliance & Auditing Services

(800) 509-0538

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

Starting January 1st, the American Medical Association (AMA) implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.

The stated reason for the need to change the Evaluation and Management (E/M) guidelines, was that the guidelines do little to support patient care. Simply put, adherence to the old E/M guidelines consume a significant amount of the physician’s time and don’t necessarily reflect the actual work by the physician.

So, in accordance with President Trump’s executive order, directing federal agencies to cut red tape, CMS proposed revisions to the E/M rules to decrease administrative burden and make code level selection more intuitive. CMS feels this will improve payment accuracy and minimize the amount of note bloating from EHR copy and pasting of the same problem list day after day.

The current E/M code set includes guidelines on using the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill.

With that said, starting on January 1st, 2021 practitioners will now document office and outpatient E/M level codes 99202—99215 based on total time on medical decision making (MDM) or the total time on the date of the encounter.

Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.

Starting with time, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes 99202 – 99215 whether or not counseling and/or coordination of care dominates the service.

When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors in each category.

The E/M services for which these guidelines apply require a face-to-face encounter with the physician.

Here are the major points from the 2021 guidelines for Time:

  • You will be able to use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
  • The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face time spent by the provider on the same day as the visit.
  • When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination or x-rays using a separate code, you should not include that in the time for the E/M code.

This is because the performance and/or interpretation of diagnostic tests/studies during a patient encounter are bundled together under a separate billing code and not included in determining the levels of E/M services. Even so, it should be documented in your records.

  • The total time also will not include time for activities the clinical staff normally perform such as taking vitals.

Physician professional time includes the following activities, when performed:

  • Preparing to see the patient (eg, intake forms and studies from other providers)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering tests or other procedures
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Documenting clinical information in the patient’s health record
  • Care coordination (not separately reported)
  • Typically, because a chiropractor cannot justify the use of the 99205/99215 codes they will not be used.
  • If coding using the 99204/99214 codes, make sure that your documentation supports its use.

The following are the time codes used as a determining factor for each category:

New patient codes:

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes

Established patient codes:

  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes

 

Remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

Additionally, It isn’t necessary to note how much time was spent in each activity but the total time for the encounter.

Describe what was done, and document time in a single statement as in the example below.

“I spent 30 minutes reviewing the patient’s intake form, examining the patient, and documenting my diagnosis and findings in the record. I also discussed treatment with the patient, including the possible risk associated with treatment and alternatives to care. The patient stated that they understood the risk and requested that treatment be performed.”

  • Though a medically appropriate history and/or examination will not be part of the basis for code selection, history and exam findings that are pertinent to the visit should still be documented.
  • Physician documentation must accurately depict what occurred during the encounter, as you still need to be covered in the event of a lawsuit or post-payment audit.
  • It’s crucial to understand that your E/M documentation must support the medical necessity of the diagnosis and treatment provided.
  • When using time as a coding factor, if a physician reviews medical records or special studies from another source on the day of the encounter, they should document what specific records or studies and their origin.

Also, the physician should sign the document with their full name and credentials (eg, DC) to show that they reviewed them.

  • Keep in mind, the AMA does not process or pay claims and as such, they are not the final word on billing policies or payment guidelines. This means that though CMS is accepting the new E/M guidelines for 2021, single payers and commercial Insurance plans may not.

So, it is your responsibility to contact the individual commercial insurance providers and make sure that they are accepting the new guidelines.

Because starting in 2021 practitioners will document office and outpatient E/M level codes 99202—99215 based on time or medical decision making (MDM), part two of this article will review the requirements for medical decision making (MDM) and the different categories associated with each E/M level code.

Knowing this information and the differences should help you in deciding which method would be best for your office.

The “Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.

_____________

All the Best,
Dr. John Davenport
Chief Compliance Officer

Locum Tenens and Compliance

By | Compliance, Insurance Coding | No Comments

As the compliance officer for Compliance & Auditing Services, I receive questions from chiropractic physicians from all over the country on chiropractic compliance.

This question came to me from a doctor in Florida looking for guidance regarding office coverage. Dr. Jonathan asked, “If I have a doc covering my office that is not in-network when I am out of the office can I still bill under my license/insurance participation? I’m asking about Medicare as well.”

This isn’t the first time I have been asked this question, so to help the other doctors who follow this site for compliance information, here is the answer to the question on locum tenens doctors.

It is a general practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing education.

These substitute physicians are generally referred to as “locum tenens” physicians and the regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee.

Medicare and many third-party payers do allow physicians to bill for services performed by locum tenens physicians during their absence and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them.

Under Section 125(b) of the Social Security Act, a regular physician may bill for the services of a locum tenens physicians if:

  • The regular physician is unavailable to provide the services.
  • The Medicare beneficiary has arranged for or seeks to receive the visit services from the regular physician.
  • The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis. You cannot pay a locum a salary or have a revenue based incentive payment agreement.
  • The locum physician does not provide or bill for services to Medicare patients over a continuous period of longer than 60 days.

Billing Procedures:

Medicare requires claims for services provided by a locum physician to include the Q6 modifier, which designates services were performed by alocum tenens physician, in box 24D of the CMS-1500 form. The regular physician’s provider identification number goes in box 24J.

Regarding all other insurance carriers, the billing procedures would typically be the same, as most carriers follow the same guidelines set forth by Medicare. It is important that you review the contract that you have with each insurance carrier that you are contracted with to make sure of their individual policies for locum physicians.

If you need a question answered or need help with office compliance, Compliance & Auditing Services is here to help. The certified specialist at Compliance & Auditing Services help chiropractors handle compliance issues and you set up a compliance program that meets all state and federal laws with confidence.

If you have any questions about Locum Tenens or  chiropractic compliance leave a comment or just call us.

 

 

Common Sense PQRS For Chiropractic Offices

By | Insurance Coding | No Comments

Medicare PQRS

The Physician Quality Reporting System (PQRS) is a reporting program that requires doctors enrolled in Medicare, Participating or Non-Participating providers, to submit data on the reporting of specified quality measures.

Beginning in 2007, PQRS was a pay-for-reporting program. Doctors were eligible to receive incentives if they reported quality measures. However, in 2013 the program transitioned from an incentive program to one that assessed penalties to doctors who did not meet the reporting requirements.

Therefore, if doctor’s offices did not successfully report on quality measures for covered services during the 2013 reporting period (Jan.1 –Dec 31,2013), those providers saw a decrease in reimbursement by 1.5% beginning on January 1, 2015.

Additionally, if doctor’s offices did not successfully report on quality measures for covered services during the 2014 reporting period, those providers will see a decrease in reimbursement by 2.0% beginning on January 1, 2016.

Though PQRS is technically not mandatory, the Patient Protection and Affordable Care Act (PPACA) mandated that Medicare is required to adjust payments for providers who do not participate in PQRS. So, from 2016 and beyond, reimbursement will be decreased by 2% and based on the reporting of quality measures from the previous two years.

To comply, doctors of chiropractic must report certain measures on eligible Medicare beneficiaries. Through the proper use of these codes, CMS hopes to establish standards and promote evidence- based best practices to reduce claim fraud and streamline the reimbursement process.

Reporting PQRS:

To report PQRS, all you need to do is place G-codes on your claims. The G-codes correlate to an action that was taken (or not taken) by the provider. As a chiropractor, you only need to report two quality measures. These measures are:

Measure #131: Pain Assessment and Follow-Up

The purpose of this measure is to show when a pain assessment is done using a standardized tool, and a follow-up plan that includes a reassessment of pain is documented.

Pain assessment tools include, but are not limited to, Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Numeric Rating Scale (NRS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS).

Measure #182: Functional Outcome Assessment

The purpose of this measure is to show when functional outcome assessments are conducted, using a standardized tool, along with the creation of a treatment plan based on the functional deficiencies found.

Functional outcome assessments measure a patient’s physical limitations when performing activities of living, such as low back pain which inhibits the patient’s ability to walk or sleep.

Standardized functional outcome assessment tool examples include Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), and the Neck Disability Index (NDI).  

G-codes:

Each Measure contains several choices of quality data codes (G-codes) that correspond to the measure to be reported. On each visit, the provider should report one of the G-codes, from each of the two measures, on line 24 D of a paper claim or on service line 24 of an electronic claim.

Measure #131: Pain Assessment and Follow-Up

  • G8730 – Pain assessment documented as positive using a standardized tool and a follow-up plan is documented.
  • G8731 – Pain assessment using a standardized tool is documented as negative, no follow-up plan required.
  • G8442 – Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool.

*Note that patients are not eligible only if one or more of the following reason(s) are documented:

  1. Patient is in an emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
  2. A severe mental and/or physical disorder and patient is unable to express their self in an understandable way by others.
  • G8939 – Pain assessment documented as positive, follow-up plan not documented,   documentation the patient is not eligible.
  • G8732 – No documentation of pain assessment reason not given.
  • G8509 – Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given.

Measure #182: Functional Outcome Assessment

  • G8539 – Functional outcome assessment documented as positive using a standardized tool and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
  • G8542 – Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required.
  • G8942 – Functional outcome assessment using a standardized tool is documented within the previous 30 days and care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
  • G8540 – Functional Outcome Assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool.

Patients are not eligible only if one or more of the following reason(s) are documented:

  1. Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
  2. The patient is unable to complete the questionnaire.
  3. The patient refuses to participate.
  • G8541 – Functional outcome assessment using a standardized tool not documented, reason not given.
  • G8543 – Documentation of a positive functional outcome assessment using a using a standardized tool; care plan not documented, reason not given.
  • G9227 – Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan.

(*See G8540 for non-eligibility reasons).

**Note that the use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.

G-code Rules:

You should report Measures #131 and #182 on every visit, for every Medicare patient who is at least 18 years old and where you have reported a spinal CMT.

You must document the name of the standardized tools used to assess the patients in the medical record. The exception would be when a provider uses a fraction for the Numeric Rating Scale (ie.6/10) when assessing pain for intensity.

Providers should report, for each visit, whether they provided a standardized pain assessment on the patient, if pain was present or absent, and, if pain was present, documented a follow-up plan that includes a reassessment of the pain.

Common Sense PQRS For Chiropractors:

First understand that Medicare pays for medically necessary treatment. Basically, this means that the patient has pain that is interfering with their ability to perform their normal daily activities (Functional Deficits).

Once a patient’s pain and, more importantly, functional deficits have improved or they have reached a plateau in their care, Medicare is no longer responsible to pay for treatment.

Because of this, the reporting of these measures ( #131: Pain Assessment and Follow-Up and Measure #182: Functional Outcome Assessment ) are required to meet the PQRS reporting standards.

With this in mind, chiropractic offices will generally document only a handful of G- codes from each of the two measures, on line 24 D of a paper claim or on service line 24 of an electronic claim.

G-codes Common Sense:  

During active care, the doctor has the patient fill out both pain and functional assessments on the Initial Visit and Re-exams.

  • G8730 – Pain assessment documented as positive using a standardized tool and a follow-up plan is documented.

This means a pain assessment was done using a standardized tool and documents the patients level of pain with a documented treatment plan that includes a planned reassessment of pain, a referral, or that the initial plan is still in effect.

In other words, chiropractors will use this code with every visit during active care and patient visits for initial exams and re-exams.

  • G8539 – Functional outcome assessment documented as positive using a standardized tool and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.

This means a functional outcomes assessment was done using a standardized tool and documents that it was preformed on the same date of service. This is typically coded only with the initial exam and re-exams during active care.

  • G8731 – Pain assessment using a standardized tool is documented as negative, no follow-up plan required.

This means a pain assessment was done using a standardized tool that documents the patient has no pain and no treatment plan is required.

  • G8942 – Functional outcome assessment using a standardized tool is documented within the previous 30 days and care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
  • The G8942 code is typically used for office visits during active part of treatment, between the initial exam and re-exams.
  • G8542 – Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required.

The G8542 code is typically used on the date of final re-exam once the patient has reached maximum medical improvement and patient is discharged from care.

The following are examples of how the G- codes are typically used.

Initial Exam And Re-exams:

  • G8730 – Pain assessment done, and a follow-up plan is documented.(CMT / Active / Tx / Exams)
  • G8539 – F0A done, care plan done (During 1st CMT / Active Tx)

Daily office visits for routine treatment:

  •  G8730- Pain assessment done, and a follow-up plan is documented.(CMT / Active / Tx / Exams)
  • G8942 –FOA done and care plan done within 30 days (CMT Visits between          RE/Active Tx)

The final Re-exam once the patient has reached maximum medical improvement and patient is discharged.

  •  G8731 – Pain assessment done, no pain using a standardized, no follow-up plan required. (Final RE/Discharge)
  • G8542 – FOA done, no deficit, no care plan needed (Final RE/Discharge)

  Finally, always remember that your assessments, exams and treatment plans must be documented in your patient files. If your records are audited, you have reported that you have correctly documented these measures.

Dr. John Davenport DCM, MCS-P

Chief Compliance Office, Certified Insurance Consultant

 

The Use And Understanding Of X{EPSU} Modifiers

By | Insurance Coding | No Comments

X Modifier PictureI’ve been getting a lot of questions about the -59 modifier and the new X modifiers, so I thought I would take some time here to explain the use of these modifiers and to let you know why most insurers, including Medicare, still continue to use the -59 modifier.

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.

The -59 modifier is the most commonly used and commonly abused modifier. According to 2013 CERT Report data, incorrect -59 modifier usage amounts to a $77 million per year overpayment.

Because of this, CMS believes that more precise coding options are needed to reduce the errors associated with this overpayment.

As a result, CMS established the following four new HCPCS modifiers, referred to collectively as -X{EPSU} modifiers, to define specific subsets of the -59 modifier:

  • XE – “Separate encounter.” A service that is distinct because it occurred during a “separate encounter.” This modifier should only be used to describe separate encounters on the same date of service.
  • XP – “Separate Practitioner.” A service that is distinct because it was performed by a different practitioner.
  • XS – “Separate Structure.” A service that is distinct because it was performed on a separate anatomical area.
  • XU – “Unusual Non-Overlapping Service.” The use of a service that is distinct because it does not overlap usual components of the main service.

These -X modifiers are intended to provide greater reporting specificity.

Though CMS will continue to recognize the -59 modifier, the Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available.

In some instances CMS may selectively require a more specific – X modifier for billing at high risk for incorrect billing.

Because the X modifiers are different versions of the -59 modifier, it would be incorrect to include both modifiers on the same line.

Though the use of the new modifiers was scheduled to start January 1, 2015, don’t hold your breath. Here’s why:

  • Chiropractors are only paid for 98940, 98941 and 98942. None of your adjustment codes would require modifier -59.
  • For now, secondary billing for Medicare is uncertain. Secondary (private) payers haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It’s likely they will adopt the same rule sooner or later, so keep an eye out for changes.
  • To date, private payers are not requiring the new modifiers. Providers such as BCBS, Aetna, and Cigna haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It is likely that they will in the future so watch for updates from private payers.

Though it is likely that the -59 Modifier days are numbered, until then continue to code as usual, with modifier -59.

If you have any questions or concerns don’t hesitate to call or email Compliance & Auditing Services (complianceandauditingservices.com) . We’re here to help you.

All The Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services