Fig. 1 CMS work time values Source: CMS


Published 9/1/2016
Sarah Wiskerchen, MBA, CPC

Commonly Asked Coding Questions

Q: Are the Centers for Medicare & Medicaid Services (CMS) and other payers requiring use of –X{EPSU} modifiers?

A: Although the four –X{EPSU} modifiers were initiated by CMS, they have also been part of the Common Procedural Terminology (CPT) manual since 2015. These four modifiers—XE, XS, XP, and XU—are used in lieu of modifier 59. The modifiers are commonly called –X{EPSU} modifiers for separate Encounter, Structure, Practitioner, and Unusual non-overlapping service referenced in the EPSU acronym.

The latest CMS directives about using the –X{EPSU} modifiers were issued last year (2015). According to MedLearn Matters (Jan. 1, 2015), SE1503, providers could continue to use modifier 59 after Jan. 1, 2015, "in any instance in which it was correctly used prior to Jan. 1, 2015." CMS also promised additional guidance and education on the appropriate use of the new –X{EPSU} modifiers.

In a May 26, 2015, revision to MedLearn Matters 8863, CMS stated that it would continue to recognize the -59 modifier in many instances, but that it may selectively require a more specific –X{EPSU} modifier for certain codes at a high risk for incorrect billing. "A particular NCCI [National Correct Coding Initiative] procedure-to-procedure edit code pair may be identified as payable only with the –XE separate encounter modifier but not the -59 or other –X{EPSU} modifiers," reads the document. "The –X{EPSU} modifiers are more selective versions of the -59 modifier, so it would be incorrect to include both modifiers on the same line."

Although CMS has still not provided specific examples of –X{EPSU} modifier scenarios, some Medicare Administrative Contracts (MACs), including Novitas, have begun offering examples on their websites. A second MAC, Noridian, stated that "Until CMS publishes instructions and examples for the four X modifiers, providers are instructed to use modifier 59 in place of the subset modifiers."

CMS has not issued any national directives about –X{EPSU} selective requirement scenarios since May 26, 2015. If modifier 59 claims are denied despite appropriate documentation to support a distinct service, practices should check with their Medicare MAC or commercial payer to determine if an –X{EPSU} modifier is required instead.

Q: What do I need to document to support using modifier 22?

Answer: In CPT, modifier 22 describes "Increased Procedural Services," formerly called an unusual service, and requires documentation that supports "the substantial additional work and the reason for the additional work, eg, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required." To secure additional payment for modifier 22 services, do the following:

Tell the story in the operative note. In addition to reporting modifier 22 on the claim, it's essential to use the operative note to support its use. Ideally, this description will be included within both a "findings" paragraph and the body of the note. Alternatively, a separate paragraph describing the rationale for the modifier can be positioned in the operative report. For example, if a patient's morbid obesity contributed to the case's complexity, the patient's body mass index (BMI) should not only be referenced in the preoperative diagnoses and findings paragraph, but the body of the note should describe the impact of the high BMI on the patient's management. This note might include the increased services required intraoperatively and also those required postoperatively in the management of this obese patient during the 90-day global period. Factors such as challenges in patient transfer, patient intubation, and the patient's ability to participate in physical therapy are reasonable considerations. Some payers may recognize that obesity presents an altered surgical field, but explanatory detail will tell the story to those that do not.

When documented, citing an altered surgical field can be a valuable supporting factor for modifier 22. Examples include total knee replacement after open reduction internal fixation of the distal femur or tibial plateau, because CPT does not include a conversion arthroplasty CPT code for the knee. Revision anterior cruciate ligament repairs and revision carpal tunnel surgery may also support use of modifier 22.

Do your homework about time. As the modifier description indicates, a variety of factors may contribute to using modifier 22. Many physicians focus only on the time option; however, time is a supporting element and does not justify increased services in itself. One reference for assessing whether intraoperative time is a credible supporting reason is the Physician Fee Schedule Final Rule, which includes a table of work time values (Fig. 1). CMS and the American Medical Association do not believe that time alone is sufficient justification since inefficiency should not be rewarded.

For example, a physician who completes a total knee arthroplasty (TKA) (27447) in 90 minutes, would not add modifier 22 with time as the only reason for the modifier because 90 minutes is actually less than the median time (100 minutes) for routine TKA surgery, according to the most recent CMS work-time survey. If, however, the case was more complex, required more work, and took longer than the work survey time, and these factors are included in the documentation, the physician will be in a better position to support the use of modifier 22. Keep in mind that not all of the "increased procedural service" may take place in the operating room; increased services could be provided preoperatively or postoperatively, depending on the patient's circumstances.

As shown in Fig. 1, 27447 includes the following time components:

  • Median preevaluation time—40 minutes
  • Median positioning time—15 minutes
  • Median pre/scrub/dress time—20 minutes
  • Median intraservice time—100 minutes
  • Immediate postoperative time—25 minutes
  • 3 postoperative office visits (99213)
  • 1 postoperative hospital visit (99231)
  • 2 postoperative hospital visits (99232)
  • 1 discharge visit (99238)

The total time for each CPT code incorporates all of the office and hospital visits, but doesn't list how much time is valued for each evaluation and management (E/M) service. However, the Work Time table does include time allocations for the E/M codes themselves, such as 23 minutes for 99213, 20 minutes for 99231, 40 minutes for 99232, and 38 minutes for 99238.

Monitor your payments and appeal. Too many practices pay no attention to modifier 22 claims once they are submitted to the payer, and make no effort to appeal them if they are initially allowed at the standard contractual rate. It's not unusual for payers to pay these claims at the standard rate, waiting for the practice to appeal. Additional reimbursement of 15 percent to 20 percent may require additional staff effort. Practices must weigh the options of receiving the standard rate in a timely manner against the potential of increased payment.

Information in this article has been reviewed by the AAOS Coding, Coverage, and Reimbursement Committee.

Sarah Wiskerchen, MBA, CPC, is a senior consultant with KarenZupko & Associates, Inc.