The Centers for Medicare and Medicaid Services announce an update to claim adjudication rules for National Correct Coding Initiative Procedure-to-Procedure edits to allow bypass of an edit if modifiers 59, XE, XS, XP, or SU are appended to either the column one or column two code.

In 2015, the Centers for Medicare and Medicaid Services (CMS) introduced the following modifiers, referred to as X{EPSU} and intended to provide more information in scenarios where modifier -59, “Distinct procedural service,” would be appropriate:

  • XE, “Separate encounter, a service that is distinct because it occurred during a separate encounter”
  • 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 non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service”

Later in 2015, CMS stated that additional guidance and education on the appropriate use of the new X modifiers would be introduced, and that modifier -59 could still be used. That additional guidance is still pending and little has been mentioned regarding the X modifiers—until recently.

This past February, CMS issued a change to the claims processing logic for CMS carriers effective July 1, 2019, involving Modifier -59, and included the X modifiers in the transmittal.

Currently, when one of the aforementioned modifiers is appended to override an edit, the Correct Coding Initiative (CCI) requires the modifier to be placed on the column 2 code of the CCI Procedure-to-Procedure (PTP) edit pair for the edit to be bypassed.1

This means that if the modifier is mistakenly placed on the column 1 code, a corrected claim needs to be resubmitted, which causes additional cost to both your practice and the payer. For example, when performing a 3.0 cm simple laceration repair to the finger that does not include the fingernail, you also performed an evacuation of a subungual hematoma. You want to be paid for performing both of those services since they were not related to each other, so you refer to the CCI edits to make sure it is billed properly.

In this case, Current Procedural Terminology (CPT) code 12002 (simple laceration repair) is in column 1 and CPT code 11740 is in column 2. Modifier -59 or modifier XS would be appended to CPT code 11740 because it is in column 2.

In July 2019, Medicare will allow a more billing-friendly approach when utilizing modifiers -59, XE, XU, XS, and XP. In the scenario above, the modifier can go on either code and it will bypass the edit.

Keep in mind, however, that you will still want to append the modifier to the procedures with the lower reimbursement on the Medicare fee schedule since that is the one that will be reduced in reimbursement. Using our scenario above, the national average payment according to the Medicare Physician Fee Schedule,2 the reimbursement for CPT code 11740 is $52.62, and the reimbursement for CPT code 12002 is $111. Thus, you would want to append the modifier to CPT code 11740 since the reimbursement is lower.

This change affects CMS carriers only, and does not apply to Medicare managed care payers, Medicaid, or commercial payers. You will want to contact those payers to see if they have limitations regarding these modifiers when it comes to the column 1 and column 2 codes. During the survey, this would also be a good time to see if those payers recognize modifiers XE, XU, XS, and XP; if so, check to see if they have any guidelines around their use.

This change in the CCI edits is the first fresh CMS reference to X modifiers in quite some time, and we should look forward to an upcoming MedLearn Matters article to provide more detail in the future.

 

References

  1. Centers for Medicare & Medicaid Services. PTP Coding Edits. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Accessed April 17, 2019.
  2. Centers for Medicare & Medicaid Services. License for Use of Current Procedural Terminology, Fourth Edition (“CPT). Available at: https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed April 17, 2019.
Be Aware: The CCI Edits, They Are a Changin’
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