Alcohol Abuse Coding: Understanding Guidelines for new XU Modifier

When a patient comes into an office for their Medicare Annual Wellness Exam, it’s common to collect necessary vitals such as height, weight and blood pressure. Another piece of information that clinicians should consider obtaining is a patient’s lifestyle assessment, including asking questions about diet, exercise, and use of tobacco and alcohol.

While patients may not go to the doctor because they are curious about their drinking, it is important to know when a habit is becoming a significant health risk. Screening for alcohol use is one of many suggested preventive screeners for physicians to administer. Doing so can become a time-consuming process, but reimbursement for the time requires knowing the proper coding and assigning the correct modifiers for a successful claim.

Modifier 59 has commonly been the “go to” for coding various services. When in doubt a 59 modifier was added to codes to bypass any coding edits in the billing process. However, most recently, the Centers for Medicare & Medicaid Services (CMS) have started to look for ways to decrease the improper use of modifier 59.

As a result, CMS has issued a new set of modifiers to encourage a greater specificity in coding. Of course, with any new coding guidelines, there is a learning curve we need to overcome and a few points that need to be considered.

Modifier 59 is related with substantial abuse and audit activity often resulting in lengthy reviews and appeals. The XU modifier is designed to reduce improper use of modifier 59 and help to improve claims processing for providers. Medicare will be using the new XU modifier to track utilization of services, and the continued overuse of modifier 59 may be a potential red flag during claims processing.

As always, documentation must support the use of any modifier. It is essential to collect the results of a patient’s preventive screening, along with the time spent discussing results or follow up plans. We will delve deeper into proper documentation in a future post.

One of the most challenging aspects of coding and reimbursement is that there is always so much to learn. Continually changing coding guidelines, along with the increased demands for documentation may seem like a steep hill to climb, but it is possible to reach the top!

Additional Resource: MLN Matters – Specific Modifiers for Distinct Procedural Services