Anthem Claims Data Audit of Distinct Procedural Service Modifiers

March 14, 2022

In January of 2022, Anthem sent educational letters out to several pathologists identifying their use of Distinct Procedural Service modifiers as “higher than average.” An audit of their claims data compared to nationally recognized standards and guidelines prompted this communication. APS responded to Anthem on behalf of our clients to clarify that we do follow CPT® Guidelines carefully, and pathology work simply requires a higher than average use of this type of modifier.

Pathology coding and billing by nature requires physicians to charge the same CPT more than once for services rendered. In the course of diagnosing tissue, our doctors use several tests and methods of preparation to identify disease processes. It is not unusual for pathology practices to use the distinct procedural modifier codes (59, XE, XP, XS, and XU) at a higher than average rate compared to other physician groups.

Pathologists are often asked to perform intraoperative consultations on one or more specimens at different anatomic locations during the same procedure, which would require the use of a distinct procedural service modifier. There is also a high volume of IHC stains, to include both qualitative and quantitative, during the same patient encounter. The volume of these types of code pairs in a pathology practice results in an increased use of the distinct procedural service modifiers. 

Our coding staff is trained to apply these modifiers only after careful review of each report, verifying that documentation in the report supports the use of the modifier and that the correct CPT codes are applied to each specimen. 

The following code pairs are often billed together in a pathology practice and our team carefully reviews for compliance before adding the modifier for distinct procedural service. This list is not all-inclusive; it represents frequent pathology CPT codes billed during the same encounter on separate sites or different encounters on the same date of service:

88360 or 88361 with 88342
88189, 88188, or 88187 with 88342
88331 with 88329 or 88334
88173 with 88112, 88108, or 88104
88305 with 88161
88108 with 88112
88104 with 88108 or 88112