Physician Practice

Coders face common problems and new challenges for drug administration in 2015

Physician Practice Insider, February 10, 2015

For the sixth year in a row, CMS and the AMA made no changes to CPT® coding or billing guidelines for drug administration services. However, they remain challenging due to what many coders see as inconsistent or conflicting guidance.

"Sometimes providers would like CMS or CPT guidance to address some of the one-off scenarios they encounter," said Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota. "But for the majority of cases providers see, the rules and CPT coding hierarchy for facility reporting are clear."

In addition to reviewing guidelines from CMS and the AMA, providers should look to their Medicare Administrative Contractor, the American Hospital Association's Coding Clinic, or CPT Assistant for additional guidance on common problem areas, she said.

However, despite static code and guidelines, some aspects of drug administration coding and billing have changed recently and lack clear guidance.

In August 2014, CMS announced four new subsets of modifier -59 (distinct procedural service), referred to collectively as the -X{EPSU} modifiers.

The new modifiers are:
• -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, a service that is distinct because it does not overlap usual components of the main service

CMS said to use these more specific modifiers in place of modifier -59, when appropriate, but did not delete modifier -59. In the transmittal, CMS noted that CPT guidelines state that modifier -59 should not be used when a more descriptive modifier is available.

In January, CMS released MLN Matters® article SE1503 to note that even though the -X{EPSU} are active, providers can continue to use modifier -59 in all instances they previously correctly reported it.

"This is a bit confusing, since many providers would argue that their previous use was appropriate and that they correctly reported modifier -59, so what does CMS’ language really mean?" Shah asked.

Perhaps it means that providers should being to report the new modifiers when it’s clear which one to use, such as with drug administration services provided at separate encounters (e.g. modifier -XE would clearly be correct) but when it’s less clear, like with -XU or -XP, perhaps modifier -59 would be more appropriate given past appropriate use, said Shah. "Certainly, drug administration services are good candidates for these modifiers, since so many claims with drug administration services alongside other services are likely to trigger an NCCI edit, where the use of modifier -59, and now one of the new modifiers, is likely appropriate."

For example, if a patient presents in the morning and receives an antibiotic infusion, then leaves and returns later in the day for another antibiotic infusion, providers to date would report both services with an initial service infusion code with one of them having a modifier -59 reported to signify two separate encounters, said Shah.

With the new modifiers in place, providers can report the more specific -XE modifier to signify that separate encounters occurred on the same date of service, she said.

This is a straightforward example of where modifier -59 would be replaced with one of the new -X {EPSU} modifiers, but what about a case where a patient receives drug administration services in two vascular access sites, with documented medical necessity for each site, during a single encounter?

Traditionally, providers have reported two initial services, one with modifier -59 appended, according to Shah. With the new modifiers, it seems to make sense that modifier -XS would be reported to signify separate sites, yet the description of modifier -XS does not include the phrase “separate site,” said Shah.

In all likelihood, separate sites is a part of the description of modifier -XS since it’s listed in the description of modifier -59, but for many, until they see this stated clearly in the description of modifier -XS, they may feel reluctant to use it to represent different sites, said Shah. In these cases, they can continue to use modifier -59.

"You'll have to determine internally when you want to start using the new modifiers given that CMS is allowing both modifier -59 and the new modifiers to be reported for now," Shah said. "The hope for many still is that CMS will release additional guidance with specific examples showcasing how the new modifiers should be used, especially modifiers -XP and -XU, so that they can be applied appropriately."

Shah urged providers to contact NCCI and CMS via the email address given in SE1503 and submit specific questions and examples about how to use the new modifiers, as this may facilitate the release of more guidance.

Information for this JustCoding article came from the HCPro webcast Injections and Infusions: Evaluate the Impact of CMS’ 2015 Changes.

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