Use of Modifiers with NCCI Edits when Clinical Circumstances are Appropriate

    By: Amy E. Rosenman, M.D. on Apr 13, 2015

    AUGS Members,

    Per Chapter 1 of the NCCI Coding Manual, entitled “General Correct Coding Policies,” modifiers may be appended to HCPCS/CPT codes only if clinical circumstances justify their use. In the retrospective to October 1, 2014 NCCI edits regarding vaginal hysterectomy, the NCCI and the Centers for Medicare and Medicaid Services (CMS) revised the edits to allow the use of NCCI approved modifiers to by-pass those NCCI edits under appropriate circumstances.

    The modifier that AUGS members may be using, when appropriate, is the -59 modifier. For the NCCI, the -59 modifier is primarily used to indicate that two or more procedures are performed at different anatomical sites or different patient encounters.

    Effective January 1, 2015 four new modifiers are available, -XE, -XS, -XP, and –XU, to provide greater reporting specificity in those situations where modifier -59 was previously reported. These four modifiers may be used in lieu of modifier 59 whenever possible. Eventually, NCCI will require the use of these modifiers rather than -59 with certain edits.

    AUGS is seeking examples from members on their experiences using these modifiers. We are interested in your experiences with both resubmission claims and new claims with the modifiers. Please email colleen@augs.org if you are willing to provide this information.

    Below are examples of how the current billing system will differ from the prior system under appropriate clinical circumstances.

    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.

    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. “

    Prior billing system: 58260 +57260-51 + 57283-51
    Current billing system: 58260 + 57260-51 + 57283-59

    Prior billing system: 58294 + 57282-51

    Current billing system: 58294 + 57282-59

    Scenario 1
    55 year old female presents with vaginal prolapse and stress urinary incontinence. Her evaluation revealed 3’ cystocele, 3’ uterine prolapsed and urodynamic stress incontinence. Vaginal hysterectomy, bilateral high uterosacral vaginal vault suspension, anterior colporraphy and midurethral sling and cystoscopy is performed.

    Original billing (before October 2014):

    58263 Vaginal hysterectomy for uterus less then 250 grams

    57283 -51 Vaginal vault suspension (intraperitoneal)

    57240 -51 Anterior colporrhaphy

    57288 -51 Sling operation for stress incontinence

    Possible billing April 1, 2015:

    58263 Vaginal hysterectomy for uterus less then 250 grams

    57283 -59 Vaginal vault suspension (intraperitoneal)

    57240 -51 Anterior colporrhaphy

    57288 -51 Sling operation for stress incontinence

    -51 Multiple procedures

    -59 Distinct procedural service

    Scenario 2
    65 year old female with POP-Q Stage II (primarily uterine and posterior vaginal wall prolapse) desires surgical intervention after a pessary trial.  She is counseled on various procedures and opts for the vaginal route.  She undergoes an uncomplicated Total vaginal hysterectomy and BSO, with a high uterosacral ligament suspension.  A cystoscopy is done multiple times during the case to assure ureteral patency.  The uterine weight is 129g.  The ovaries are normal in size and appearance.

    The coding that is applicable today is:

    58262 (total vaginal hysterectomy and BSO, wt < 250g)

    We cannot code for the uterosacral suspension (57283) or the cystoscopy (52000) as they are currently bundled.

    After April 1, 2015, we can re-submit for the case with a 59 modifier:

    58262

    57283 -59

    Scenario 3
    66 YOWF with POPQ stage 3 prolapse who presents for pessary fitting. Point C -4. Leading edge is Ab +3

    Gelhorn pessary fitted and pt instructed in use.

    ICD 9 - 618.2

    ICD 10 - N81.3

    Scenario 4
    A surgeon performs a vaginal hysterectomy, combined AP repair and high uterosacral suspension, then does a cystoscopy to ensure there is no GU injury

    Original billing (before October 2014):

    58260 – vaginal hysterectomy

    57260-51 AP repair, with multiple procedure modifier

    57283 – 51, intra-peritoneal vaginal colpopexy

    52000 – 51, cystoscopy

    Possible billing April 1, 2015:

    58260

    57260-51  (revised edits no longer excludes this pair)

    57283-59 (NCCI modifier necessary to override the pair edit 58260+57283)

    Note:  cystoscopy can no longer be separately billed, effective 1/1/15

    Scenario 5
    A surgeon performs a vaginal hysterectomy with enterocele repair, a combined AP repair, and a SSLS

    Original billing (before October 2014):
    58270 – TVH+enterocele repair

    57260-51, AP repair

    57282 – 51, SSLS

    Possible billing April 1, 2015:
    58270

    57260-59, (new edit bundles TVH-enterocele with AP repair, but can be overridden with modifier)

    57282-59 (new edit bundles TVH-enterocele and SSLS, but can be overridden with modifier)

    Scenario 6
    A surgeon intends to perform a LAVH and L/S colpopexy, however, after the LAVH, he converts to an open sacral colpopexy because of technical difficulty.

    Original billing (before October 2014):
    58550 – LAVH

    57280 – 51, abdominal sacral colpopexy, with a multiple procedure modifier

    Possible billing April 1, 2015:
    58550

    57280-59 (new edit bundles the two procedures, but can be overridden with a modifier)

    Scenario 7
    A surgeon performs a LAVH, and then does a sacrospinous ligament suspension to correct apical prolapse.

    Original billing (before October 2014):
    58550

    57283-51 SSLS

    Possible billing April 1, 2015:

    58550

    57283-59 (this pair of codes is now bundled, but it can be overridden with a 59 modifier)


    Thank you,

    Amy Rosenman, MD
    AUGS President


    Disclaimer:
    The Coding and Reimbursement Committee of the American Urogynecologic Society (AUGS) assists members with the application of governmental regulations and guidelines regarding terminology and CPT/ICD coding in urogynecologic practice. Such information is intended to assist with the coding process as required by governmental regulation and should not be construed as policy sanctioned by AUGS. AUGS disclaims liability for actions or consequences related to any of the information provided.  AUGS does not endorse the diagnostic protocol or treatment plan designed by the provider.

     

    Released: April 13, 2015, 10:32 am
    Keywords: Announcements | coding


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