Choose the correct modifier
Some payers may require the CPT modifier –59 for the majority of these cases. A list of the payers that require the more specific –X (E, S, P, U) modifiers should be kept and referenced. The definitions of the –X modifiers are as follows:
• XE: Separate encounter
• XS: Separate structure/organ
• XP: Separate practitioner
• XU: Unusual non-overlapping services.
In some cases, it may be more appropriate to use a location modifier in place of modifier –59 or one of the –X modifiers. Location modifiers such as –LT and –RT are designed to communicate that a procedure, considered bundled if provided on the same side, was actually provided on the contralateral side during the same operative session. An example would a stent insertion on the right side during the same session as a lithotripsy and stent insertion on the left side. Proper coding for this situation would be 52356 –LT and 52332 –RT. As location modifiers provide more specificity than the other modifiers, it is recommended that these modifiers be used to report bundled procedures if applicable. (Note: –RT and –LT should not be reported if the same procedure is provided on both sides of the body; instead, modifier –50 should be appended to the code indicating the same procedure was provided on separate sides of the body at the same session.
Accuracy is key. Never routinely add modifiers to unbundle procedures just because they’re bundled. This, unfortunately, is the routine for many billers.
As you can see, there are many opportunities for lost revenue or inappropriate billing. Start with the documentation. Merely saying the procedure was performed is not adequate. You must document the details of the service performed if you expect to get paid. Probably the biggest mistake we see is inadequate communication between the provider and the billers. Start at the beginning and make sure that you and your billing team are on the same page. Follow selected patient claims through the billing process to make sure that everyone is on the same page. Finally, get some feedback from your billing support team.
A little time is worth a lot in terms of peace of mind, and the resulting return on investment will be obvious.
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.