Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Transcription

1 Subject: Modifiers 59 and XE, XP, XS, XU NY Policy: 0023 Effective: 03/01/ /31/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs. DESCRIPTION A modifier is made up of two alpha and/or numeric characters that are appended to a Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code. A modifier is used as a means of reporting a specific circumstance that further defines or alters the code but it does not change the definition of the procedure performed or item procured. Modifier 59 is described by CPT as identifying a distinct procedural service. Appendix A of the CPT manual states that Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 1 Modifiers XE, XP, XS, and XU (referred to collectively as X{EPSU} modifiers) are described by HCPCS as modifiers to be used for a distinct separate encounter (XE), separate practioner (XP), separate structure (XS), or unusual non-overlapping service (XU) and are considered subsets of modifier 59 for selective identification. This policy documents the Health Plan s position on reimbursement and reporting services with modifiers 59, XE, XP, XS, or XU for CMS-1500 submitters. POLICY The Health Plan accepts modifier 59 for claims processing, but not always to determine reimbursement. Modifier 59 and X{EPSU} are important to the adjudication of the claim because it may result in the override of edits within the Procedure Unbundling ClaimsXten Rule. I. Procedure Unbundling: occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. Procedure unbundling edits include three components: Incidental, Mutually Exclusive, and Rebundling. See also our Claim Editing Overview Policy for additional ClaimsXten rule information. NY 0023 Page 1 of [5]

2 When modifier 59 or X{EPSU} are appended to a reported procedure code, our claims editing system will override most incidental, mutually exclusive, and rebundling denials, and allow separate reimbursement for that procedure. The incidental, mutually exclusive, and rebundling edits are not overridden when a different diagnosis is submitted, with a line item procedure code, without a modifier to identify a distinct procedural service. However, a different diagnosis alone does not justify the use of modifiers 59 or X{EPSU}. Unlisted procedures are not affected by modifiers 59 or X{EPSU}. II. Reporting and Documentation Rules and Criteria for Modifier 59: The reporting of modifier 59 or X{EPSU} by a provider must follow the Health Plan s requirements for correct coding. The Health Plan requires that modifier 59 or X{EPSU} must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits We follow CPT coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. 2 Documentation is not required for a claim to be processed when modifier 59 or X{EPSU} are appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. The Health Plan follows CPT in requiring that documentation must support: a different session or patient encounter a different procedure or surgery a different anatomical site or organ system a separate incision/excision a separate lesion a separate injury The following example indicates the appropriate use of modifier 59 or an X{EPSU} modifier when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported. A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, will be denied separate reimbursement. When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 or XE to CPT is warranted to signify that a separate and NY 0023 Page 2 of [5]

3 distinct service was performed. (Modifier 59 or XE should follow modifier 26, if services are done in a facility setting.) Modifier 59 or XE will override the procedure unbundling edit and will be eligible for separate reimbursement. III. Exceptions to Distinct Modifier Override: The Health Plan has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 or X{EPSU} to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending distinct procedural modifier to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement (See also our Screening Services with Evaluation & Management Services and our Bundled Services and Supplies reimbursement policies.): Duplicate coding Services and supplies specified in the Bundled Services and Supplies Policy E/M or DME item codes National Correct Coding Initiative (NCCI) edit code pairs with a superscript of zero, or a modifier allowance indicator of zero. When the denial of a code is supported by CPT parenthetical language that indicates a code is not reportable with specific other code(s) (e.g., do not report xxxxx with yyyyy...), distinct procedural service modifiers will not override the denial In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples: reported with reported with when reported with 22600, 22610, 22612, and when reported with or reported with 29806, 29807, 29821, and reported with (unless reported with an American Academy of Orthopaedic Surgeons approved diagnosis) reported with 29880, 29881, and reported with 29880, 29881, and (unless reported with an American Academy of Orthopaedic Surgeons approved diagnosis) reported with 96360, 96365, 96374, 96375, 96376, 96405, 96406, 96409, 96413, 96416, 96440, 96446, 96450, and/or and reported with E/M codes , and reported with , 58145, 58146, 58545, and reported with 58570, 58571, or , 58771, or when reported with reported with NY 0023 Page 3 of [5]

4 reported with , 63047, reported with or 22633, same interspace with 22551, 22552, 22554, and with 22612, 22614, 22558, 22585, and (unless limited circumstances are met, such as spinal fracture, spinal infection, or spinal tumor) XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (These code ranges include all applicable radiology interpretation codes, as well as radiology codes with modifier 26) reported with and reported with reported with reported with reported with , 77002, 77003, and that are indicated as not reportable with specific other codes per CPT parenthetical statements (e.g. do not report in conjunction with ) reported with reported with 77280, 77285, and/or reported with 80322; reported with and 80326; reported with 80326; reported with 80328; reported with and 80331; reported with 80331; reported with and 80334; reported with 80334; reported with and 80337; reported with 80337; reported with and 80341; reported with 80341; reported with and 80344; reported with 80344; reported with 80347; reported with and 80352; reported with 80352; reported with and 80364; reported with 80364; reported with 80370; reported with and 80377; and reported with , 82542, and/or reported with and reported with reported with , 83992, and G0480-G reported with ,83992, and G0480-G , , and reported with , , G0101, G0402, G0438, G0439, S0610, and S reported with G , 93018, 93042, and 0180T reported with reported with 95940, 95941, or G reported with reported with 95950, 95951, 95953, 95954, and on the same date or on subsequent dates of service reported with NY 0023 Page 4 of [5]

5 , 96369, 96372, 96373, 96374, and reported with nuclear medical testing codes , 99152, 99153, 99155, and reported by the same provider with the codes previously identified in Appendix G of the 2016 CPT codebook (See also our Moderate (Conscious) Sedation reimbursement policy for code list.) 40. A4215 reported with A4221, A4222, E0776, E0781 and S9810 reported with any per diem home infusion therapy (HIT) code such as S5492-S5502, S9061, S9325-S9379, S9490-S9504, S9537- S A4250 reported with urinalysis codes A4556 and A4557 reported on the same date of service and/or within a 30 day period with electrical stimulator supplies code A A4556 reported with related electrical cardiography codes 93XXX, neurology, sleep study and neuromuscular codes 95XXX; electrical stimulation codes 97014, , ; and home sleep studies G0398-G A4595 reported with 97014, A4648 reported with and/or G0268 reported with , , H2019 reported with H J2001 reported with , 27096, L8680 reported with Q0091 reported with , , and S6010-S6013 1Current Procedural Terminology, cpt 2016, Professional Edition, pg Ibid CPT is a registered trademark of the American Medical Association ClaimsXten is a registered trademark of McKesson Information Solutions LLC Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield. NY 0023 Page 5 of [5]