In my previous post, I have shared about how to use XE modifier while coding medical charts in medical coding. In this post, I will tell you how the documentation of the report is given for applying XE modifier in coding. As we know, XE is modifier is used when there is different encounter by the same patient on same day with the same physician. So, we will check it out with the sample reports for using XE modifier for coding live charts.
First Report or First Encounter for XE modifier
Exam: THREE VIEWS OF THE RIGHT WRIST.
Time: 5/6/2015 7:22:56
Reason for Exam: Pain
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FINDINGS: There are comminuted and displaced fractures involving the distal radial metaphysis and epiphysis, fracture extends to the distal articular surface, where there is approximately 5.3 mm of distraction of the fracture site. No carpal bone fracture is identified.
So, here in the above report patient has come with a pain and the physician find a fracture in the distal radial metaphysic and epiphysis. The procedure code for the above report will be 73110-RT.
Second Report or Second Encounter for XE modifier
EXAM: DX Wrist 2 Views RT
Time: 5/6/2015 9:12:54
Reason for Exam: post reduction
Findings: Two postreduction views of the right wrist demonstrate decreased displacement of the comminuted fracture of the distal radial metaphysis and epiphysis, the fracture line at the distal articular surface now has approximately 1 mm or less of displacement. There is no carpal bone fracture or dislocation.
Cast has been placed
Now, in the above second encounter the patient again comes after two hours to the same physician for the reduction of the fracture. Now, the procedure code for the second encounter is 73100-RT. So, there is difference in levels in procedures hence there will be CCI edit between these two procedure codes. Hence, here in such situation we will use X-Encounter modifier to differentiate between these two procedures for different encounter. So, the final CPT code will be 73100-RT,XE.