Modifiers XE, XS, XP, XU, and 59 - Usage Guidelines



Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service


Scope

This policy applies to all Commercial medical plans, Medicare Advantage plans, and Oregon Medicaid/EOCCO plans.

Reimbursement Guidelines Effective for dates of service January 1, 2015 and following, Moda Health will accept modifiers XE, XS, XP, and XU and will expect providers to use modifiers XE, XS, XP, and XU in place of modifier 59 when appropriate.

• Modifier 59 should not be used when one of the -X{EPSU} modifiers describes the reason for the distinct procedural service. The -X{EPSU} modifiers are more specific versions of the -59 modifier.

• It is not appropriate to bill both modifier 59 and a -X{EPSU} modifier on the same line. CPT codes submitted with modifiers XE, XP, XS, XU, or 59 appended will be considered separately reimbursable when all of the following apply:

• The clinical edit is eligible for a modifier bypass (e.g. per edit rationale, CCI modifier indicator = “1”, etc.).

• CMS policy on the -X{EPSU} modifiers is evolving. If CMS indicates a specific edit may only be bypassed with a specific -X{EPSU} modifier but is not eligible for a bypass with the other -X{EPSU} modifier options or with modifier 59, Moda Health will follow those specific requirement as well.

“For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.” (CMS 5 )

• The CPT code is not considered a bundled component of a more comprehensive procedure (code definitions, standards of medical & surgical practice, etc.).

• The modifier and the code have been submitted in accordance with AMA CPT book guidelines, CPT Assistant guidelines, CMS/NCCI Policy Manual guidelines, and any applicable specialty society guidelines.

• The medical records documentation supports the appropriate use of modifiers XE, XP, XS, XU, or 59.

• The procedure code is eligible for separate reimbursement according to the status indicators on the CMS fee schedule for the relevant provider type (physician fee schedule, ASC, OPPS, etc.).

The submission of modifiers XE, XP, XS, XU, or 59 appended to a procedure code indicates that documentation is available in the patient’s records which will support the distinct or independent identifiable nature of the service submitted with modifier XE, XP, XS, XU, or 59, and that these records will be provided in a timely manner for review upon request.

Modifiers XE, XP, XS, XU, and/or 59 do not bypass multiple surgery fee reductions, bilateral fee adjustments, or any other administrative policy other than clinical edits. Appropriate use of modifiers XE, XP, XS, XU, or 59:

Separate surgical operative session on the same date of service (e.g. 8 AM surgery with one procedure, 4 PM surgery with second procedure code).


modifer XE


Modifier XP is a little unclear. Once possible scenario might be:

The patient is seen in the office by a family practice physician, who in the course of the visit encounters a problem outside their scope of ability so calls in (or arranges an immediate transfer to) a specialist physician at the same claim to perform the needed service.

modifer XP 

• May be the same encounter.

• Is definitely the same clinic/TIN.

• Different provider specialties apply.

• E/M service may normally be included in the therapeutic treatment or minor surgical procedure.


Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550- XS).

modifer XS 

• Same encounter

• Different anatomical site and contralateral structure.

• (Note: 20550 is not eligible for modifiers LT or RT.) Separate injury (or area of injury in extensive injuries).

XS versus

modifer 59

Depending upon your specific circumstances XS or 59 may be most appropriate.

A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter.) For example, diagnostic cardiac angiography leads to therapeutic angioplasty.

See CCI Policy Manual, chapter 1, modifier 59 guidelines. (CMS 2 )

modifier XU versus 59

Depending upon your specific circumstances XU or 59 may be most appropriate.

Benign skin lesion (0.7 cm) removed from left posterior ribs (11401) and benign skin lesion (0.4 cm) removed from right arm (11400-59).

modifier 59

• Same encounter

• Same organ system and/or structure (skin)

• Different lesions.

Diagnostic mediastinoscopy via midline incision (39400) and thoracoscopy of right lateral lung via lateral incision with biopsy of pleura (32609-XS??). Different organ system (e.g. laparoscopy on separate organ systems).

modifier 59
• Same encounter

• Same organ system (respiratory)

• Different incision.

Colonoscopy with snare removal of polyp in transverse colon (45385) and bipolar cautery of polyp in descending colon (45384-59). 59

• Same encounter

• Same incision or orifice (rectum)

• Different/separate lesions.


CMS may in the future release further clarification and/or example scenarios for these modifiers.We’ll update these examples as new information is made available.

Incorrect use of modifiers XE, XP, XS, XU, or 59:

• Procedures in the same anatomical site (e.g. digit, breast, etc.), even with incision lengthening or contiguous incision.

• CPT identified “separate” procedures performed in the same session, same anatomic site, or orifice.

• Laparoscopic procedure converted to open procedure.

• Incisional repairs are part of the global surgical package, including deliveries and cosmetic improvement of a previous scar at the location of the current incision.

• Contiguous structures in the same anatomic site or organ system. (See Coding Guidelines “Different Organs/Contiguous Structures” and CCI Policy Manual, chapter 1. (CMS 2 ))

• Modifier XP should not be used to identify two providers of the same specialty in the same clinic to bypass global surgery package rules, new-patient visit edits, or other same-specialty rules.

• Appending XE, XP, XS, XU, or 59 to Evaluation and Management (E/M) codes instead of using modifiers -24 or -25.


Background Information

Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code.

CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS). Like CPT codes, the use of modifiers requires explicit understanding of the purpose of each modifier. Modifiers provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

• To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery

• To indicate that a procedure was performed bilaterally

• To report multiple procedures performed at the same session by the same provider

• To report only the professional component or only the technical component of a procedure or service

• To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit)

• To indicate special ambulance circumstances More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes. Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational.

Modifiers are not intended to be used to report services that are "similar" or "closely related" to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.


Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 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. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same day, see modifier 25.

Effective for dates of service January 1, 2015 and following, CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU, and collectively they are referred to as -X{EPSU}.

The -X{EPSU} modifiers are more selective versions of the -59 modifier. (CMS 4, 5)


Modifier Modifier Definition

Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate

Encounter

Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A

Different Practitioner

Modifier XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service



Definition of Terms Term Definition

Ipsilateral On the same side; affecting the same side of the body; the opposite of contralateral.

In paralysis, this term is used to describe findings on the same side of the body as the brain or spinal cord lesions producing them. Contralateral On the opposite side; originating in or affecting the opposite side of the body, the opposite of homolateral and ipsilateral.

Coding Guidelines

“Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.”


“Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.”

Paired Structures, Ipsilateral versus Contralateral

“It is very important that NCCI-associated modifiers only be used when appropriate. In general these circumstances relate to separate patient encounters, separate anatomic sites or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations. However, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized.” 2

Different Procedure or Surgery

“One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe “different procedure or surgery”. The code descriptors of the two codes of a code pair edit consisting of two surgical procedures or two diagnostic procedures usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter.


The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.” 2


Different Diagnosis

“Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.” 2

Different Organs/Contiguous Structures

“From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.” (CMS 2 )

“If multiple bacterial blood cultures are performed, including isolation and presumptive identification of isolates, code 87040, Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate), should be used to identify each culture procedure performed. Modifier 59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.” 3

Relationship of Modifiers XE, XP, XS, and XU to Modifier 59

“These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier…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.” (CMS 4 ) “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” (AMA 1 )



Modifier Description

XE Separate encounter Service that is distinct because it occurredduring a separate encounter.

XP Separate practitioner Service that is distinct because it was performed by a different practitioner.

XS Separate structure Service that is distinct because it was performed on a different organ/structure.

XU Unusual nonoverlapping service The use of a service that is distinct because it does not overlap usual components or the main service.




Modifiers

Modifier billings with ClaimsXten

ClaimsXten has some very strict edits on procedure versus modifier. If the modifier is not valid for the procedure, the claim line will be denied. Some examples/guidelines are:

• Modifier 50, bilateral, is not valid on a procedure with bilateral in the description or with PT/OT codes.
• RT or LT is not valid on a procedure with bilateral in the description (i.e. radiology)
• Modifier 26 is not valid with surgical procedures
• Site specific modifiers are not appropriate with Evaluation and Management codes.
• Be sure the modifier is valid by using the CPT and/or HCPCS book.
• Repeat clinical diagnostic lab procedures should be billed with Modifier 91 and NOT with Modifier76.
• Specific finger modifiers (F1-F9 and FA) are not valid with procedures specific to the hand.
• Specific toe modifiers (T1-T9 and TA) are not valid with procedures specific to the foot.
• Modifier AT is only valid with CPT codes 98940-98943
• Modifiers 24 and 25 are only valid with Evaluation and Management codes.

Modifier 25

Modifier 25: Significant, separately identifiable Evaluation and Management service by the same physician on the same day of the procedure or other service. It is important to bill modifier 25 with Evaluation and Management code IF a provider is performing an unrelated separate procedure. For example, when providing a minor surgery service, the visit on that day is included in the payment for the procedure.

However, when performing an E&M service unrelated to the minor surgical procedure, providers should append modifier 25 to the E&M code. If it is appended to the surgery code, the surgery line will be denied for incorrect coding. The same criterion applies when providing other procedures, including chemotherapy administration, allergy injections, chiropractic manipulation, etc. The visit is included in the other procedure codes unless it is a separate and identifiable E&M procedure.

Some criteria for the appropriate use of modifier 25:
• Are there signs, symptoms, and/or conditions that the physician must address before deciding to perform a procedure or service?
• Was the evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?
• Is there more than one diagnosis present that is being addressed and/or affecting the treatment or outcome?

Modifier 59
• Modifier 59: Distinct procedural service. A more detailed article regarding modifier 59 was printed in the September 2010 issue of Providers’ News. Please refer to that article for complete billing instructions.
• Modifier 59 only applies to non-E&M services. If submitted with an E&M service, the E&M service will be denied as incorrect coding.
• Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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.
• No other established modifier is appropriate, i.e., multiple or bilateral surgery.
• Modifier 59 should be used with caution.
When a procedure is described in the CPT code descriptor as a “separate procedure” but is carried out independently or is unrelated to other services performed at the same session, the CPT code may be reported with modifier 59.




Present On Admission (POA) indicator list and reporting requirement


Present On Admission (POA) Indicators Scope Description:

Applies to Present On Admission (POA) Indicator requirement for all BlueCross BlueShield of TN lines of business.

Subject:  Present On Admission (POA) requirement Purpose:

To establish guidelines for Present On Admission (POA) Indicator requirement Standard:

POA indicators are needed when Acute Inpatient Prospective Payment System (IPPS) Hospital providers bill for selected Hospital Acquired Conditions (HACs), including some conditions on the National Quality Forum’s (NQF) list of Serious Reportable Events (commonly referred to as "Never Events"), these certain conditions have been selected according to the criteria in section 5001(c) of the Deficit Reduction Act (DRA) of 2005 and are reportable by The Centers for Medicare & Medicaid Services (CMS) POA Indicator Options:

· Y = Diagnosis was present at time of inpatient admission.

· N = Diagnosis was not present at time of inpatient admission.

· U = Documentation insufficient to determine if the condition  was present at the time of inpatient admission.

· W = Clinically undetermined. Provider unable to clinically  determine whether the condition was present at the time  of inpatient admission.

· 1 = Unreported/Not used. Exempt from POA reporting. This  code is equivalent to a blank on the UB-04, therefore;  for paper claims, in this instance, leave the space blank  and a “1” will automatically be assigned


Present On Admission (POA) Indicators

 Claims will be rejected if:

 · POA “1” is submitted on a paper UB04 inpatient claim
 · POA equal space is submitted on an electronic inpatient claim
 · POA is required but not submitted

BlueCross BlueShield of Tennessee (BCBST) began accepting POA indicator codes on inpatient hospital claims effective January 1, 2008.


Note: BlueAdvantage lines of business will follow CMS Billing Guidelines.

Present On Admission (POA) Indicator


Note: This article was updated on June 5, 2013, to reflect current Web addresses. This article was previously revised on September 11, 2007, to clarify the timeframes for reporting the POA indicators. All other information remains unchanged.



Background

Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on admission (POA) of patients effective for discharges on or after October 1, 2007. By October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) will have selected at least 2 high cost or high volume (or both) diagnosis codes that:

• Represent conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines; and

• When present on a claim along with other (secondary) diagnoses, have a DRG assignment with a higher payment weight. Then, for acute care inpatient PPS discharges on or after October 1, 2008, while the presence of these diagnosis codes on claims could allow the assignment of a higher paying DRG, when they are present at the time of discharge, but not at the time of admission, the DRG that must be assigned to the claim will be the one that does not result in the higher payment.

Beginning for discharges on or after October 1, 2007, hospitals should begin reporting the POA code for acute care inpatient PPS discharges. There is one exception, i.e., claims submitted via direct data entry (DDE) should not report the POA codes until January 1, 2008, as the DDE screens will not be able to accommodate the codes until that date.

Between October 1, 2007, and December 31, 2007, CMS will collect the information on the hospital claim, but does not intend to provide any remittance or other information to hospitals if the information is not submitted correctly for each diagnosis on the claim. Hospitals that fail to provide the POA code for discharges on or after January 1, 2008 will receive a remittance advice remark code informingthem that they failed to report a valid POA code. However, beginning with discharges on or after April 1, 2008, Medicare will return claims to the hospital if the POA code is not reported and the hospital will have to supply the correct POA code and resubmit the claim. In order to be able to group these diagnoses into the proper DRG, CMS needs to capture a Present On Admission (POA) indicator for all claims involving inpatient admissions to general acute care hospitals. CR 5499, from which this article is taken, announces this requirement and provides your fiscal intermediaries (FI) and A/B MACs with the coding and editing requirements, and software modifications needed to successfully implement this indicator. Note: Adjustments to the relative weight that occur because of this action are not budget neutral. Specifically, aggregate payments for discharges in a fiscal year could be changed as a result of these adjustments.

These POA guidelines are not intended to replace any found in the ICD-9-CM Official Guidelines for Coding and Reporting, nor are they intended to provide guidance on when a condition should be coded. Rather, you should use them in conjunction with the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each “principal” diagnosis and “other” diagnoses codes reported on claim forms (UB-04 and 837 Institutional). Information regarding the UB-04 Data Specifications may be found at http://www.nubc.org/become.html on the Internet.

Note: Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, and children’s inpatient facilities are exempt from this requirement.

The following information, from the UB-04 Data Specifications Manual, is provided to help you understand how and when to code POA indicators:

1. General Reporting Requirements

• Pertain to all claims involving inpatient admissions to general acute care  hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.

• Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
• POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider. • If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
2. Reporting Options and Definitions
• Y - Yes (present at the time of inpatient admission)
• N – No (not present at the time of inpatient admission)
• U - Unknown (documentation is insufficient to determine if condition is present at time of inpatient admission)
• W – Clinically undetermined (provider is unable to clinically determine whether condition was present at time of inpatient admission or not)
• 1 -- Unreported/Not used – Exempt from POA reporting (This code is the equivalent of a blank on the UB-04, but blanks are not desirable when submitting data via the 4010A1.

The POA data element on your electronic claims must contain the letters “POA”, followed by a single POA indicator for every diagnosis that you report. The POA indicator for the principal diagnosis should be the first indicator after “POA,” and (when applicable) the POA indicators for secondary diagnoses would follow. The last POA indicator must be followed by the letter “Z” to indicate the end of the data element (or FIs and A/B MACs will allow the letter “X” which CMS may use to identify special data processing situations in the future). Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL 67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on claims submitted electronically via 837, 4010 format, you must use segment K3 in the 2300 loop, data element K301.

Below is an example of what this coding should look like on an electronic claim:

If segment K3 read as follows: “POAYNUW1YZ,” it would represent the POA indicators for a claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y), the first secondary diagnosis was not POA (N), it was unknown if the second secondary diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the fifth secondary diagnosis was POA (Y). As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA data and POA data will also be included with any secondary claims sent by Medicare for coordination of benefits purposes.

See the complete instructions in the UB-04 Data Specifications Manual for more specific instructions and examples.

Note: CMS, in consultation with the Centers for Disease Control and Prevention and other appropriate entities, may revise the list of selected diagnose from time to time, but there will always be at least two conditions selected for discharges occurring during any fiscal year. Further, this list of diagnosis codes and DRGs is not subject to judicial review.

Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder. Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized.

NOTE: You, your billing office, third party billing agents and anyone else involved in the transmission of this data must insure that any resequencing of diagnoses codes prior to their transmission to CMS, also includes a resequencing of the POA indicators.


Present on Admission (POA) Indicators

Required by Blue Cross and Blue Shield of Kansas

Effective with inpatient discharges as of April 1, 2007 and after, BCBSKS requires all hospital providers to appropriately code POA indicators as part of their inpatient claim and record.

This BCBSKS requirement:
• Applies to all inpatient discharges of April 1, 2007 or after.
• Required for all contracting and non-contracting hospital providers.
• Required for all hospitals including critical access hospitals etc. that may be exempt from this requirement by other payers such as Medicare.
• Does not apply if Medicare is the primary payer.
• Applies to inpatient claims when another insurance company (excluding Medicare) is the primary payer. BCBSKS will require POA information on inpatient claims even if the primary payer did not require the information.

Present on admission is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery are considered as present on admission. POA indicators are assigned to principal and secondary diagnoses and the external cause of injury codes.

The reporting options for all diagnosis reporting are as follows:

CODE DEFINITION
Y Yes – Present at time of admission
N No – Not Present at time of inpatient admission
U No information on record – insufficient documentation
W Clinically Undetermined – Provider is unable to determine whether or not diagnosis was Present upon Admission

Blank Exempt from POA Reporting
* (effective 7/1/11) Exempt from POA Reporting
* UB-04 only; not for use on 837

The following pages list all diagnosis codes that are exempt from POA reporting and do not require a POA indicator effective October 1, 2013. This list is updated every October by the National Uniform Billing Committee (NUBC).


 ICD-9DIAGNOSIS ICD-9 NOMENCLATURE POA EXEMPT

E0000 CIVILIAN ACTIVITY DONE FOR INCOME OR PAY Y
E0001 MILITARY ACTIVITY Y
E0002 VOLUNTEER ACTIVITY Y
E0008 OTHER EXTERNAL CAUSE STATUS Y
E0009 UNSPECIFIED EXTERNAL CAUSE STATUS Y
E0010 ACTIVITIES INVOLVING WALKING, MARCHING AND HIKING Y
E0011 ACTIVITIES INVOLVING RUNNING Y
E0020 ACTIVITIES INVOLVING SWIMMING Y
E0021 ACTIVITIES INVOLVING SPRINGBOARD AND PLATFORM DIVING Y
E0022 ACTIVITIES INVOLVING WATER POLO Y
E0023 ACTIVITIES INVOLVING WATER AEROBICS AND WATER EXERCISE Y
E0024 ACTIVITIES INVOLVING UNDERWATER DIVING AND SNORKELING Y
E0025 ACTIVITIES INVOLVING ROWING, CANOEING, KAYAKING, RAFTING AND TUBING Y
E0026 ACTIVITIES INVOLVING WATER SKIING AND WAKE BOARDING Y
E0027 ACTIVITIES INVOLVING SURFING, WINDSURFING AND BOOGIE BOARDING Y
E0028 ACTIVITIES INVOLVING WATER SLIDING Y
E0029 OTHER ACTIVITY INVOLVING WATER AND WATERCRAFT Y
E0030 ACTIVITIES INVOLVING ICE SKATING Y
E0031 ACTIVITIES INVOLVING ICE HOCKEY Y
E0032 ACTIVITIES INVOLV SNOW (ALPINE) (DOWNHILL) SKIING, SNOW BOARDING, SLEDDING, ETC. Y
E0033 ACTIVITIES INVOLVING CROSS COUNTRY SKIING Y
E0039 OTHER ACTIVITY INVOLVING ICE AND SNOW Y
E0040 ACTIVITIES INVOLVING MOUNTAIN CLIMBING, ROCK CLIMBING AND WALL CLIMBING Y
E0041 ACTIVITIES INVOLVING RAPPELLING Y
E0042 ACTIVITIES INVOLVING BASE JUMPING Y
E0043 ACTIVITIES INVOLVING BUNGEE JUMPING Y
E0044 ACTIVITIES INVOLVING HANG GLIDING Y
E0049 OTHER ACTIVITY INVOLVING CLIMBING, RAPPELLING AND JUMPING OFF Y
E0050 ACTIVITIES INVOLVING DANCING Y
E0051 ACTIVITIES INVOLVING YOGA Y
E0052 ACTIVITIES INVOLVING GYMNASTICS Y
E0053 ACTIVITIES INVOLVING TRAMPOLINE Y
E0054 ACTIVITIES INVOLVING CHEERLEADING Y
E0059 OTHER ACTIVITY INVOLVING DANCING AND OTHER RHYTHMIC MOVEMENTS

CPT code Q2034, Q2035, Q2036, Q2037, Q2038 and Q2039

Procedure code and Description

Q2034: Influenza virus vaccine, split virus, for intramuscular use (Agriflu)

Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (AFLURIA)

Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (FLULAVAL)

Q2037: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluvirin)

Q2038: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluzone)

Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use


Vaccination:



 An injection of a killed microbe in order to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations, or immunizations, work by stimulating the immune system, the natural diseasefighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To only immunize against bacterial diseases, it is generally possible to use a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the Effectiveness of immunizations can be improved by periodic repeat injections or “boosters.”


Clients age 19 and older

This section applies to clients age 19 and older. Refer to the Professional Administered Drugs Fee Schedule for a listing of covered vaccines for clients age 19 and older. Codes with a fee are paid according to the Professional Administered Drugs Fee Schedule.

Note: DOH supplies free vaccines for children 0-18 years only. For clients 18 years of age and younger, see the agency’s Early and Periodic Screening,

Diagnosis and Treatment (EPSDT) Program Billing Guide.

• Bill the agency for the cost of the vaccine by reporting the procedure code for the vaccine given.
• Bill for the administration of the vaccine using CPT codes 90471 (one vaccine) and90472 (each additional vaccine). Reimbursement is limited to one unit of 90471 and one unit of 90472 (maximum of two vaccines).
• Bill for administration of nasal vaccine using CPT code 90473 (one vaccine) and 90474 (each additional vaccine). Reimbursement is limited to one unit of 90473 and one unit of 90474 (maximum of two vaccines).
• Providers are reimbursed for the vaccine using the agency’s maximum allowable fee schedule.
• Providers must bill 90471 and 90472 on the same claim as the procedure code for the vaccine.

If an immunization is the only service provided, bill only for the administration of the vaccine and the vaccine itself (if appropriate). Do not bill an E/M code unless a significant and separately identifiable condition exists and is reflected by the diagnosis. In this case, bill the E/M code with modifier 25. If the E/M code is billed without modifier 25 on the same date of service as a vaccine administration, the agency will deny the E/M code. Exception: The E/M code 99211 cannot be billed with a vaccine or the vaccine administration code.

Note: Meningococcal vaccines (CPT codes 90733 and 90734) require EPA. See EPA #870000421.

For Medicare beneficiaries, the seasonal influenza vaccine is usually administered once a year during the fall or winter months. Additional influenza vaccines (ie, the number of doses of a vaccine or the type of influenza vaccine) are covered by Medicare when medically necessary. Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part D covered drug.


FREQUENTLY ASKED QUESTIONS

Does the Medicare Part B deductible, coinsurance, or copayment apply for Part B-covered immunizations?
When physicians or suppliers agree to accept assignment, the Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus, pneumococcal, and Hepatitis B vaccines or their administration.

If a beneficiary gets a seasonal influenza virus vaccine twice in a 12-month period, will Medicare still pay for it?
Yes, Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could get the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons, and Medicare would pay the provider for each. For example, a beneficiary who received a seasonal influenza virus vaccination in January 2018 for the 2017–2018 influenza season could receive another seasonal influenza virus vaccination in November 2018 for the 2018–2019 influenza season, and Medicare would pay for both vaccinations.

Should providers administer the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history?

Yes, if a beneficiary is uncertain about his or her vaccination history, and the provider cannot obtain verification from the beneficiary’s medical records, provide the vaccine. Medicare beneficiaries are eligible for the initial pneumococcal vaccine and a different pneumococcal vaccine one year after the first vaccine (at least 11 months have passed following the month when the last pneumococcal vaccine was administered).

Beneficiaries may be liable for the costs of the revaccination if they exceed the benefit maximum or if the timing of these services is sooner than the required 11 full months following the month of the last pneumococcal vaccine. We encourage providers to closely track vaccination history.

Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?

No, Medicare covers the hepatitis B vaccine for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include health care professionals who have frequent contact with blood or blood-derived body fluids during routine work, individuals with End-Stage Renal Disease (ESRD), individuals living with an HBV carrier, and individuals diagnosed with diabetes mellitus. Other situations could qualify a beneficiary as being at intermediate or high risk of contracting HBV. Medicare beneficiaries not eligible for this benefit are those currently positive for hepatitis B antibodies.

CPT 99050, 99051, 99053, 99056, 99058, 99060 - Service after hours

Procedure code and description

99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service

99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service

99060 Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service



Services Outside of Business Hours
Texas Medicaid limits reimbursement for after-hours charges (procedure codes 1-99050, 1-99056, and 1-99060) to office-based providers rendering services after routine office hours and/or on an emergency basis. An office-based provider may bill an after hours charge in addition to a visit for providing services after his/her routine office hours. This should be billed when a provider, in his/her clinical judgment, deems it medically necessary to interrupt his/her schedule to care for a client with an emergent condition. A provider’s routine office hours are those hours posted at the physician’s office as the usual office hours.

Texas Medicaid reimburses office-based physicians an inconvenience charge when any of the following exists:

The physician leaves the office or home to see a client in the emergency room.

The physician leaves the home and returns to the office to see a client after the physician’s routine office hours.

The physician is interrupted from routine office hours to attend to another client’s emergency outside of the office. Charges for inconvenience or after hours services, by emergency department-based physicians or emergency department-based groups are not reimbursed separately.


Policy Overview

After hours or weekend care (CPT®) codes represent services provided,when anindividual physicianor other health care professionalis required to render the services outside of regular posted office hours to treat a patient's urgent illness or condition.This policy outlines when after hours or weekend care codes are considered for separate reimbursement.

Reimbursement Guidelines

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for Current Procedural Terminology (CPT®) codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into the payment for other services provided on the same day.

CPT Codes 99053, 99056, 99058 or 99060

Consistent with CMS, UnitedHealthcare will not separately reimburse CPT codes 99053, 99056, 99058 or 99060.

CPT Codes 99050 and 99051

Although CMS considers CPT codes 99050 and 99051 to be bundled into the payment for other services provided on the same day, UnitedHealthcarewill provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic servicesand CPT code 99051 in addition to acute care services (not preventive  medicine codes).

UnitedHealthcare will reimburse after hours CPT codes99050 and 99051 to participating primary care providers when reported in one of the following CMS non-facility place of service (POS) designations only:

**School (CMS POS 03)
**Indian Health Service Free-standing Facility (CMS POS 5)
**Tribal 638 Free-Standing Facility (CMS POS 7)
**Office (CMS POS 11)**Independent Clinic (CMS POS 49)
**Federally Qualified Health Center (CMS POS 50)
**State or Local Public Health Clinic (CMS POS 71)
**Rural Health Clinic (CMS POS 72)UnitedHealthcare will reimburse the following participating primary care providers for CPT codes 99050and 99051:
**Adolescent Medicine, Pediatric-Adolescent, Pediatrics    
**Family Nurse Practitioner, Nurse Practitioner, Pediatric Nurse Practitioner, Advanced Registered Nurse Practitioner     
**Family Practice**General Practice**Geriatric Medicine**Gynecology, Obstetrics & Gynecology, Obstetrics**Internal Medicine**Certified Nurse Midwife


Q: Why doesn't UnitedHealthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?
A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hours as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

2Q:  When will UnitedHealthcare provide reimbursement for CPTcode 99050?
A:  UnitedHealthcare will provide reimbursement for CPT code 99050 during times other than regularly scheduledoffice hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.

3Q:  When will UnitedHealthcare provide reimbursement for CPT code 99051?
A:  UnitedHealthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).


CPT Code 99050 and 99051

Although CMS considers CPT codes 99050 and 99051 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes and CPT code 99051 in addition to acute care services (not preventive medicine codes).

Oxford will reimburse after hours CPT code s99050and 99051 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:

POS Code Description

03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71State or local public health clinic
72 Rural health clinic

Oxford will reimburse the following participating primary care providers for CPT codes 99050and 99051:

* Adolescent medicine, pediatric-adolescent, pediatrics
* Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
* Family practice
*General practice
* Geriatric medicine
* Gynecology, obstetrics & gynecology, obstetrics
* Internal medicine
* Certified nurse midwif


POLICY from BCBS insurance
CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.

CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

• It is reported with an office setting place of service;
• It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours;
and
• The basic service time is based on arrival time, not actual time services commence.

CPT code 99050 is not eligible for separate reimbursement when it is reported with a preventive diagnosis and/or a preventive service.

CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours. CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

• It is reported with an office setting place of service; and
• The basic service time for evening hours is based on arrival time, not actual time the service commenced.
Adjunctive E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement.

CPT G0446. G0447, G0473 - Obesity counseling

CPT code and Description

G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes

G0447 – face-to-face behavioral counseling for obesity, 15 minutes

G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes.

Reimbursement Guidelines

For eligible adult health plan members with obesity, defined as Body Mass Index (BMI) equal toor greater than 30 kg/m2, Optum will align reimbursement with Medicare including:

One face-to-face visit every week for the first month;
One face-to-face visit every other week for months 2-6; and
One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.

  For adult members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

These visits must be provided by a qualified health care provider.For eligible children and adolescent (6-18 years) health plan members with overweight, defined as having an age/gender-specific BMI at or above the 85th percentile, Optum will align reimbursement with the recommendations of the U.S. Preventive Services Task Force.

CPT codes for obesity screening and counseling are: 

• 99401 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes

99402 – preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes

HCPCS codes related to obesity screening and counseling are:

G0446 – annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes•

G0447 – face-to-face behavioral counseling for obesity, 15 minutes

G0473 – face-to-face behavioral counseling for obesity, group (2–10), 30 minutes.

Modifier Description
GQ Via asynchronous telecommunications system

GT Via interactive audio and video telecommunication systems

Place of Service Code Description

02   Telehealth11Physician’s office

19   Off Campus-Outpatient Hospital

22   On Campus-Outpatient hospital

Billing Requirements - Medicare Guidelines

Diagnostic Codes


Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) for G0447  is 1.  (ICD-10 codes will be Z68.30-Z68.39, Z68.41- Z68.45)

Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, V85.41-V85.45).

Claims submitted with HCPCS G0447 that are not submitted with these diagnosis codes will be denied with the following messages:

•Claim Adjustment Reason Code (CARC) 167 – "This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

•Remittance Advice Remark Code (RARC) N386 – "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp

•Group Code PR (Patient Responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file). . If you do not have web access, you may contact the contractor to request a copy of the NCD."

•Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file)



Insurance Coverage

For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS covers

• One face-to-face visit every week for the first month;
• One face-to-face visit every other week for months 2-6;
• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement as discussed below

At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional  face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg (6.6 lbs)  over the course of the first six months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg (6.6 lbs) during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six month period.


Intensive behavioral intervention should be consistent with the 5-A framework:

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.Effective July 2, 2012, for claims processed with dates of service on or after November 29, 2011, Medicare will pay for G0447 with appropriate ICD-9  code no more than 22 times in a 12-month period. 

Effective January 1, 2015, for claims processed with dates of service on or after January 1, 2015, Medicare  will pay for G0447 and G0473 with appropriate ICD-9 code (ICD-10-CM code beginning October 1, 2015) no more than 22 times in a 12-month period

Medical Billing Popular Articles