Last month, YO Info explained CCI edits and how to decode them. Here, we provide a few examples to show when unbundling is appropriate — and when it’s not— and dig deeper into the most commonly used modifier in medicine, -59.
When Not to Unbundle
Example 1. Because of endophthalmitis, you determined that the patient required:
CPT code 67015 Vitreous tap
CPT code 65800 Paracentesis
CPT code 67028 Intravitreal injection
HCPCS code JXXXX drug
According to CCI edits, the injection is bundled with both the vitreous tap and paracentesis. The claim should be submitted as 67015 -[eye modifier], 65800 -[eye modifier], JXXXX drug code since the vitreous tap has the highest allowable.
If the injection was inappropriately submitted with modifier -59, it would have been paid incorrectly. (Payers do post-payment reviews on services submitted with modifier -59 to confirm that they were submitted correctly.) In this case, the funds would be recouped.
Example 2. The patient is scheduled for CPT code 15823 Blepharoplasty, upper eyelid, with excessive skin, and you request that a visual field be performed the same day.
According to CCI edits, CPT code 15823 is mutually exclusive of CPT code 92081 Visual field; limited (as of Jan. 1, 1996) and CPT code 92082 Visual field; intermediate (as of Jan. 1, 1998). If the test is performed the same day as the blepharoplasty, it is not separately billable, even when you apply modifier -59.
Remember that an indicator of 0 specifies these two codes can never be unbundled and are considered mutually exclusive. If you submit the visual field the same day as the blepharoplasty, most payers will reimburse for the lower allowable of the two services.
When to Unbundle
The patient has a traumatic cataract and vitreous hemorrhage caused by impact with a blunt object. You schedule the following procedures:
CPT code 67036 PPV
CPT code 66984 Cataract extraction with IOL
PPV and cataract extraction were bundled as of July 1, 2001. In this case, it is appropriate to append modifier -59 because you knew before surgery that the patient needed both procedures. Append modifier -59 to CPT code 66984 because this is the secondary procedure submitted on the claim due to its lower allowable. Payment would be 100 percent of the PPV procedure and 50 percent of the cataract surgery.
Understanding Modifier -59: Distinct Procedural Service
The most commonly used modifier in medicine, -59, is on the watch list of all payers. According to CMS, “Modifier -59 is an important National Correct Coding Initiative–associated modifier that is often used incorrectly.” As a result, many Medicare administrative contractors have denied a large numbers of claims because of the modifier’s inappropriate use.
The modifier was created to report when services are “separate and distinct” from one another, but it should not be used to bypass the CCI edits for payment. To provide more clarity, CMS released four new modifiers in January 2015. These “X” modifiers are much more detailed and should be used in place of -59 when their descriptors are met.
Although Medicare Part B has adopted these new modifiers, be sure to confirm with all of your payers before using:
-XE Separate encounter
Example: The patient has a scheduled glaucoma pressure check in the morning and returns to the office after being hit in the eye with a tennis ball.
-XS Separate structure
Example: Procedures that are bundled are being performed on contralateral eyes.
-XP Separate physician
Example: The patient sees a retina physician and glaucoma physician from the same practice on the same day. In your documentation, both of you should be focused on the reason the patient presented.
-XU Unusual non-overlapping service
Example: The service is distinct because it does not overlap usual components of the main service.
When to Expect Payments
Getting timely payments depends on knowing the latest bundling edits and how they impact procedures you perform on a daily basis. Claims usually take about 14 days to process. Any denials will take at least another 14 days to process once they’ve been corrected.
Visit AAOE’s website for the most current CCI edits published April 1.
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About the author: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series.