Compare Payer Rates for Diagnostic and Procedure Codes

By Michelle Dick
Feb 4th, 2015

Physicians Practice results are in for the 2014 Fee Schedule Survey, showing how much physicians are paid for common services. From around the country, 1613 physician practices participated. Respondents submitted how much they are paid for major diagnostic codes for new and established patients, and for common procedure codes.

Private payers do not publicly disclose payment information; however, Physicians Practice found a way to get the data by conducting this physician survey. Check out the results.

OIG Recommends Reducing Hospital Outpatient Payments to Match ASC Rates

By John Verhovshek
Feb 4th, 2015

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has recommended that the Centers for Medicare & Medicaid Services (CMS) reduce outpatient prospective payment system (OPPS) payment rates for ambulatory surgical center-approved procedures on beneficiaries with no-risk or low-risk clinical needs in outpatient departments.

The report “Medicare and Beneficiaries Could Save Billions If CMS Reduces Hospital Outpatient Department Payment Rates for Ambulatory Surgical Center-Approved Procedures to Ambulatory Surgical Center Payment Rates” argues that the change could save Medicare and beneficiaries could save $12 billion during a five-year period if CMS reduces hospital outpatient department payment rates for ambulatory surgical center (ASC)-approved procedures to the same level as ASC payment rates.

OIG: 2014 Another Record Year for Healthcare Payment Recoveries

By John Verhovshek
Feb 4th, 2015
1 Comment

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) oversight and investigations efforts are expected to recover a record-breaking $4.9 billion to the government for fiscal year (FY) 2014. Each recent year has established a new record, with $4.3 billion recovered in 2013 and $4.2 billion recovered in 2012. Total Federal healthcare payment recoveries as a result of OIG actions have more than doubled, in the past decade.

According to HHS OIG Media Communications

  • The $4.9 billion in expected recoveries for FY 2014 consist of nearly $834.7 million in program audits and about $4.1 billion in investigative work, including approximately $1.1 billion in areas such as States’ shares of Medicaid restitution.
  • OIG also reported $15.7 billion in estimated savings resulting from legislative, regulatory, or administrative actions that were supported by report recommendations.
  • OIG excluded 4,017 individuals and entities from participation in Federal health care programs in FY 2014.
  • OIG reported 971 criminal actions against individuals or entities that engaged in crimes against some of the 100 HHS programs overseen by OIG.
  • 533 civil and administrative cases, including false claims and unjust-enrichment lawsuits, were filed in Federal district court and civil monetary penalties administrative matters, which included both OIG-initiated actions and provider self-disclosures.
  • Medicare Fraud Strike Force efforts resulted in the filing of charges against 228 individuals or entities, 232 criminal actions, and $441 million in investigative receivables.

For providers, the message is clear: Compliance enforcement has become a powerful weapon for cost containment. Government entities and private, alike, are aggressively monitoring providers for potential noncompliance; both to minimize healthcare fraud, waste, and abuse, and to recover funds paid for improper claims. An effective compliance plan is essential for every healthcare provider—not only to protect patients and meet legal and contractual requirements, but to ensure economic survival.

Specific Modifiers for Distinct Procedural Services

By Rae Jimenez
Feb 3rd, 2015

By Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CPCO

There have been quite a few blogs and articles lately addressing Medicare’s new -X{EPSU} modifiers to describe subsets of the 59 modifier for “distinct procedural service” via Transmittal 1422 Change Request 8863, dated August 15, 2014, effective on January 1, 2015. They go into detail describing the definitions of each X modifier, but they have not given examples. I thought I would use this as an opportunity to provide some examples of how we would use each of the X modifiers.

The 59 modifier covers multiple situations when a “distinct procedural service” may take place. From the AMA CPT® description of the modifier:

Documentation must support a:

  • Different session;
  • Different procedure or surgery;
  • Different site or organ system;
  • Separate incision/excision;
  • Separate lesion; or
  • Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual

Medicare’s Take on X{EPSU}

The MedLearn Matters (MLN) article (MM8863) on these new HCPCS Level II modifiers break down the correct usage of the 59 modifier and more align to the situations in which the 59 is used.

They indicate that the 59 modifier should only be used in the following three circumstances:

• Different encounters
• Different anatomic sites
• Distinct services

Interestingly, the MLN article indicates specific guidelines that the 59 modifier should be used:

• Infrequently (and usually correctly) used to identify a separate encounter
• Less commonly (and less correctly) used to define separate anatomic sites
• More commonly (and frequently incorrectly) used to define a distinct service

Medicare is concerned that the 59 modifier is not necessarily being used at the proper times and that the documentation is not present to support its use. As I have taught, the 59 modifier is the “Prednisone of modifiers”. It is very powerful and when appropriate, it can get us paid for both procedures when they are normally bundled, but under these special circumstances as outlined above in the bullets, they should not be bundled this time. But like Prednisone, which also can be a very toxic drug, use of the 59 modifier when the documentation does not support its use, when one of the above situations do not exist, just to get paid for two bundled procedures, it is very dangerous and non-compliant.

Medicare is concerned about allowing bundled pairs to be bypassed with the 59 modifier and the potential for abuse. By adding these four more specific HCPCS Level II modifiers, Medicare is getting additional information as to what special circumstances existed to justify the unbundling.

Medicare took the above six possible reasons to unbundle two bundled codes and broke them into four categories. They include the following:

• XE (Separate encounter) – this applies to the “different session” or possibly “different procedure or surgery” in the 59 modifier description
• XS (Separate structure) – this includes the “separate incision/excision”, “different lesion”, and “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description
• XP (Separate practitioner) – this can include a possibly “different procedure or surgery”, “different session”, or “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description. Key to this modifier is that a different surgeon in the practice (same group NPI) performs the second procedure.
• XU (Unusual non-overlapping service) – The use of a service that is distinct because it does not overlap usual components of the main service) – “different procedure or surgery”, “different session”, or “separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” in the 59 modifier description. Key to this modifier is that the two procedures are rarely performed together.

Application of X{EPSU}

So, let’s look at some examples of specific situations when the new -X{EPSU}modifiers might be used:

• XE (Separate encounter) – The physician performs a diagnostic nasal endoscopy at 10 a.m. (31231) The patient goes to the ER at 8 p.m. that evening with severe epistaxis, so the doctor uses complex techniques to control the anterior epistaxis (30903). The diagnostic endoscopy is bundled with the control of epistaxis if they were done during the same encounter. Since they were done at different encounters, the XE would be used with the 30903 because it is the column 2 code.

Another example of a separate encounter would occur when we have a patient who has a post-operative bleed. Control of hemorrhages are considered inclusive to most surgeries. But when the patient is closed and brought to recovery, goes home, or to their inpatient room and then a post-operative bleed is detected causing them to return to the OR to control the hemorrhage will require a 59 modifier today. For Medicare, the XE modifier will be applied to the post op bleed control code which took place during a separate operative session.

• XS (Separate structure) – Two codes that often get unbundled inappropriately are bone marrow aspiration, 38220 and bone marrow biopsy, 38221. They are not permitted to be coded together unless they are performed at different sites. So, if the physician performs a marrow biopsy on the left hip and has documented medical necessity to perform a bone marrow aspiration on the right hip, both procedures can be coded and billed and as of January 1st, 2015, the XS should be applied. You have to make sure that the separate sites are not just used in order to get the doctor paid for both procedures and that there is medical necessity documented for performing both procedures and using two separate sites in order to use either a 59 modifier or with CMS the XS modifier. The 30220 would get the XS modifier since it is the column 2 code.

Another example of the XS modifier can be found in my favorite specialty, Otolaryngology. The surgeon often performs one procedure in the left sinuses and a bundled service (component code) in the right sinuses (or visa versa). The only way to get paid for these two bundled codes performed on the left and right is to use the 59 modifier. Now, for a Medicare patient, as of January 1st, we would use the XS modifier. For example, if an endoscopic total ethmoidectomy (31255) is performed on the left and only an endoscopic partial ethmoidectomy (31254) is performed on the right side, both these bundled codes can be coded, with the XS going on the 31254, the column 2 code.

• XP (Separate practitioner) – Unlike separate encounter and separate structure, this alternative would be used much more infrequently. This modifier is used when one doctor in the group does a service and another practitioner in the practice does another service that’s bundled with the first. There has to be medical necessity documented for using the two different practitioners for these two bundled procedures. I believe you might see this in the care of trauma patients, when multiple physicians care for the patient at the same time.

• XU (Unusual non-overlapping service) – Sometimes CPR is done while the patient is under anesthesia because the patient is not emerging from anesthesia. The anesthesiologist may have to resuscitate the patient using CPR. This is part of anesthesia services. In this case, the anesthesia services and CPR are bundled. But if CPR is performed as an emergency procedure because the patient codes, it is separately coded and billable for the anesthesiologist. Instead of using a 59 modifier with the 92950 and 92953 as we currently apply, an XU modifier would be used as of January 1st.

Most situations fall under XE and XS definitions since most situations when a provider reports a distinct service is when a separate encounter or separate site is involved. The other two,  XP and XU would be rarely used because these situations occur rarely in medical practices. Of course, the type of practice you have and types of procedures and services your physicians perform will influence the frequency of utilization. Use of the 59 modifier and ultimately for Medicare, the -X{EPSU} could be cause for a red flag to be raised if the frequency is high, in particular, higher than your peers. That will be reason for audit requests. Make sure your documentation supports the utilization of any modifier indicating a “distinct service” so that you can pass any audit with flying colors.

By the way, Medicare does say that you can keep using the 59 modifier, but I believe that they will use that as a reason to also red flag a practice. They are requesting voluntary compliance with the -X{EPSU} modifiers in order to track utilization and it will not look very good if your practice is not willing to comply with this request, in my opinion.

Resources: To read the transmittal and MLN Matter article, go to the CMS website.

Better Health, Better Healthcare and Lower Costs with Quality Improvement

By Rae Jimenez
Feb 3rd, 2015
1 Comment

By  Rhonda Buckholtz, CPC, CPMA, CPCI, CGSC, CPEDC, CENTC
Vice President, ICD-10 Training and Education

CMS has launched numerous programs and models to help health providers achieve large-scale transformation since the ACA was launched. Programs and models, such as the Hospital Value-Based Purchasing Program, Accountable Care Organizations, and the Partnership for Patients initiative with Hospital Engagement Networks, are striving to help clinicians and hospitals move from volume-based towards patient-centered quality health care services. The thought is to pay for quality, not quantity. CMS states this has resulted in fewer unnecessary hospital readmissions, reductions in healthcare-associated infections and hospital-acquired conditions, and improvements in quality outcomes and cost efficiency. Lower costs will be a goal but only with health improvement.

CMS estimates that only about 16 percent or 185,000 of the nation’s clinicians currently participate in existing programs, models, and initiatives that facilitate practice transformation.

The Transforming Clinical Practice Initiative is one of the largest federal investments uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks that facilitate large-scale practice transformation. Transformation will allow movement and adaptation.

CMS will award cooperative agreement funding for two network systems under this initiative: Practice Transformation Networks and the Support and Alignment Networks.

Practice Transformation Networks are designed to coach, mentor, and assist clinicians in developing core competencies to practice transformation. Clinical practices are allowed to become actively engaged. The most important is that health outcomes will improve.

Support and Alignment Networks provide the workforce development using national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. These will be made up of medical/specialties societies and those others helping provide evidence-based education and offerings.


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