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ICD-10CM Archives - Compliance and Auditing Services

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

ICD-10: How To Code 7th Character Extensions

By | ICD-10 | No Comments

Screen Shot 2015-09-23 at 10.14.40 PMFor chiropractic physicians transitioning to ICD-10, most of the time they will be using chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue.) For injuries however, they’re more likely to use chapter 19 (Injury, Poisoning & Other Certain Consequences of External Causes).

Chapter 19 codes are easy to identify in the tabular list because of the “S” at the beginning of each of these codes. The “s” codes represent conditions such as sprains and strains as in the following example, S13.4XXA, Sprain of Cervical Spine Ligaments, Initial Encounter.

The confusion comes in when the code asks for a seventh character extension. These are sometimes called the encounter codes.

As you look for a specific injury code in chapter 19, you will see directly underneath the code category or “Block,” the directions that the code requires a 7th character.

Example:

______________________________________________________

S13 Dislocation and sprain of joints and ligaments at neck level

The appropriate 7th character is to be added to each code from category S13

A initial encounter

D subsequent encounter

S sequela

______________________________________________________

 

The official guidelines indicate the following:

A – Initial encounter:

As long as patient is receiving active treatment for the condition.

D – Subsequent encounter: (CONSIDERED MAINTENANCE CARE)*

After patient has received active treatment and is receiving  routine care for the                condition.

S – Sequela:

Complications or conditions that arise as a direct result of a condition.

(e.g., scar formation after a burn)

 

Chiropractic physicians should always use the “A” character with injury codes as long as they feel the patient should be receiving “active treatment” and can show that the patient is improving with the treatment provided.

At seminars, I am often asked, “What If The Patient Comes Back To Your Office In Three Months With The Same Condition?” My answer is code “A” for active care.

To Medicare and the insurance companies, coding “D” means maintenance care and that means you will be denied payment.

When I queried the insurance companies, such as Anthem and Blue Cross Blue Shield they defer to Medicare rules.

So for now, “A” stands for active care and “D” stands for maintenance care when it comes to reimbursement from payers.

Dr. John Davenport DCM, CCSP, FIAMA, MCSP

Chief Compliance Officer

FCPA Compliance Adviser

About the Author

Dr. Davenport ran his own clinic for many years. He now provides expert witness testimony, insurance consulting, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker.

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It’s Time To Get Ready For ICD-10

By | ICD-10 | No Comments

helpThe Boy Scout motto was to be prepared. Are you? It’s been my experience as a compliance consultant that when it comes to compliance the vast majority of doctors are completely unprepared for the increased regulation and scrutiny.

This may not surprise you, but according to recent surveys 80% of all providers will not be ready by October 2015, and the percentage is probably higher for chiropractors.

What is perhaps more shocking, is how few of the payers are ready or estimated they would have a finished product ready by the end this year. Only 40%.

I can understand the procrastination of most chiropractors in getting ready. They don’t have a lot of extra time and extra staff around to dedicate to the task.

It’s not time to “panic” yet, but to make a smooth transition
to the October, 2015 deadline, there are several things you can begin doing now.

Bear in mind that even though the number of codes will grow from 17,000 to 140,000, you only need to know the codes that relate directly to chiropractic.

You and your staff will need training in multiple formats. Compliance & Auditing Services’ members will get the codes with explanations and how to cross check for the appropriate codes. Members also have webinars and the training newsletter to make it easy, with unlimited email to get answers to any questions.

It will be too late to learn this new language once ICD -10 goes “live,” because you will be behind the curve.

First, identify how ICD -10 will effect your practice.

1. How will ICD-10 effect your people and processes? To find out, review how and where staff and doctors use ICD-9.

2. Ask your payers and vendors (software systems, clearinghouses, billing services) about ICD-10 readiness. Ask when they will start testing, how long they will need, and how you and other clients will be involved.

3. Develop a plan for communicating with staff and business partners about ICD-10.

4. Estimate and secure budget (potential costs include updates to practice management systems and government payment delays.

5. Ideally, have a cash reserve of at least 3 months operating expenses so your office will be able to continue to function normally.

6. Work on your documentation. ICD-10 codes are much more specific and your documentation will need to improve to match them.

➢ This is important because if the insurance carriers ask for documentation to justify the codes, poor documentation will slow the process down or result in all out denials.

So for now, focus on these first steps in preparing your office for the ICD-10 transition and don’t sweat it.

Together we will make it easy to stay on track. After all, you have better things to do with your time than worry about the constant changes.

Dr. John Davenport
Chief Compliance Officer