Clinical editing updates: Antepartum visits; modifier 59; repeat radiology procedures

In support of correct coding and payment accuracy, we are providing the information below to keep you informed about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial

Reminder: Antepartum visits should be reported with a date span

Antepartum procedure codes *59425 and *59426 must be reported with a date span indicating the first initial visit in the from field and the last visit before delivery in the to field. 

Claims submitted without the required date span may be denied.

Following are the code descriptions:

• *59425 — Antepartum care only; 4-6 visits
• *59426 — Antepartum care only; 7 or more visits

Reminder: Inappropriate modifier combination with modifier 59

Modifier 59 is used to identify procedures and services, other than evaluation and management services, that aren’t normally reported together but are appropriate under the circumstances. When another already established modifier is appropriate (XE, XP, XS or XU), it should be used rather than modifier 59.

In accordance with the Centers for Medicare & Medicaid Services, it’s not appropriate for modifier 59 to be reported with modifiers XE, XP, XS or XU on the same claim line. When these modifiers are billed together, claims may be denied.

Following are the modifier descriptions:

• XE — Separate Encounter, a service that is distinct because it occurred during a separate encounter.
• XS — Separate Structure, a service that is distinct because it was performed on a separate organ/structure.
• XP — Separate Practitioner, a service that is distinct because it was performed by a different practitioner.
• XU — Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

Medicare Plus Blue℠

Reminder: Repeat radiology procedures

To ensure correct processing of claims, append the appropriate modifier when submitting claims for repeat radiology procedures. Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. Claims submitted for repeat radiology procedures without the appropriate modifier may be denied.

Modifier 76 definition: Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day.

Modifier 77 definition: Repeat procedure or service by another physician or other qualified health care professional.

Note: Please submit a corrected claim; don’t send clinical editing appeals.