ICD-10 Coding: Watch Out for Sneaky Modifiers for Stone Disease Treatment

Without clear guidance, a lot of -X_ and -59 modifier usage is up to your discretion

There are times when coding for stones in the urinary tract may feel as painful as actually having one—namely, when discerning which modifier to use for ipsilateral multiple stones. Many guidelines are vague and open to interpretation. Not only that, you and payers may not agree on what “different systems” in the urinary tract are—and that means only one thing: denials.

ICD-10 coding for stone disease treatment is often difficult, but there are specific actions you can take to avoid claims denials and lost revenue, even in the face of changing rules for 2019, says physician and urology professor Michael Ferragamo in his live audio conference with AudioEducator. During his presentation on ICD-10-CM coding for urology in 2019, Ferragamo walks you through tricky issues such as coding rules for treating multiple stones within the urinary tract and coding for “second look” procedures when treating stone disease.

Correct Modifier Use Benefits Patients

As a coder, you know physicians’ reimbursement depends largely on the success of claims you submit—but your best coding practices benefit patients too.

Take modifiers, which are intended to recognize the extra work of the physician and to provide a fuller picture for the payer. That’s especially key when coding for ipsilateral (same side of the body) multiple stones.

Why? Patients with several stones need to have all the stones removed—otherwise patients risk future, unnecessary trips to the operating room to remove other stones. So getting physicians paid for removing all the stones discourages them from opting to remove only the most problematic stone.

Of course, at the end of the day, you can’t control what payers (especially private payers) will accept or deny.

Best advice? Know each payer well so you only bill for what they’ll accept and lower your risk of claims denials. But also be confident and prepared with an appeal to any erroneous denials.

The Difficulty of Defining ‘Separate Structures’

A complexity of coding for stone disease treatment is the confusion over how to answer the question: “What constitutes a separate structure?”

According to the latest American Urology Association (AUA) statement, you shouldn’t bill for the removal of two stones in the same structure or organ, but the distinctions between anatomical elements aren’t always clear.

According to the Urology Care Foundation, the urinary tract consists of the following main parts:

  • Kidney
  • Ureter
  • Bladder
  • Urethra

However, it can be difficult to determine where one structure ends and the other begins, such as with the kidney parenchyma and renal pelvis. (Hint: This could be a target area for claims denials).

What to do? Work with each payer to determine what they would consider a same or different structure, and bill accordingly.

When to Use Modifier -XS or -59

Earlier in this decade, Medicare became aware of the overuse of modifier 59, Distinct Procedural Service, and therefore created the X modifiers intended to define specific subsets of -59.

There are 4 -X_ modifiers, but the one of greatest interest here is -XS, used to describe a service performed on a separate organ/structure. In order to properly use this modifier, you’ll have to have evidence in the documentation that each stone was removed from (what the payer would define as) a separate structure.

Also, when deciding between -XS and -59 modifiers, look first at whether the payer is private or Medicare. Medicare widely accepts either -59 or -XS under appropriate circumstances, while private payers are more likely to accept -59. Each payer should have it clearly defined for you which they will take.

2019 ICD-10 Coding Starts Now!

As a urology coder, diagnosis coding for stone disease treatment is a daily affair. But it’s getting trickier by the minute thanks to changes in the 2019 ICD-10-CM—which are already in effect (as of October 1)! Don’t get left behind. Be sure you understand new treatment clinical scenarios and billing policy changes for Medicare and commercial payers, notes Ferragamo.

To join the conference or see a replay, order a DVD or transcript, or read more

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