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    Modifiers for multiple stones raise questions

    AUA recommends not charging for multiple stones in single kidney or single ureter

    We have never seen so many changes in coding and billing for any service that would equal the changes we’ve seen for reporting multiple stones in the urinary system. Over the past 3 years, we’ve witnessed multiple opinions and differing payment results.

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    You might recall that we first published an article based on Medicare’s rules allowing for the reporting of treatment of separate lesions (“How to bill for stones in the same kidney”). Based on Medicare’s ruling and our understanding of the intent of this ruling, our article stated that you could bill separately for the treatment of multiple stones using the principle that a stone was no different than a lesion in work effort when in fact the stone was non-contiguous and diagnosed prior to treatment.

    The AUA then received a letter from Niles R. Rosen, MD, head of the National Correct Coding Initiative, stating that it was not permissible to bill for multiple stones at any location on the same side in the urinary system, based on the fact that stones were not lesions. The AUA appealed that decision.

    Last August, Medicare, in an effort to further reduce an identified abuse of modifier –59, introduced a new series of modifiers –X (E, S, P, U) to be used in place of modifier –59 in Medicare. The “X” modifiers were implemented on Jan. 1, 2015 and provide a new set of definitions for separate procedures. These new definitions provide a fresh look at multiple procedure allowance.

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    The reason Dr. Rosen cited for not billing for multiple stones has now been changed and may again allow billing for multiple stones when extra work effort is provided and supported by documentation. Unfortunately, Medicare has not published detailed instructions on how to use the modifiers. Therefore, the correct use of at least two of the modifiers could be interpreted in several ways. We anticipate that Medicare will publish additional regulations and/or details on their recommended use in the near future.

    NEXT: AUA weighs in on modifier use

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    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.

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