CMS Establishes Four New Modifiers to Define Subsets of -59 Modifier

The Centers for Medicare & Medicaid Services (CMS) has announced (pdf) it is establishing four new HCPCS modifiers to define specific subsets of the -59 modifier.

Modifier -59 is used to define a "distinct procedural service." It indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

According to CMS, the -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass the Medicare National Correct Coding Initiative. As CMS notes, this modifier is associated with considerable abuse and high levels of manual audit activity, which leads to reviews, appeals and even civil fraud and abuse cases.

According to an AAPC report, the introduction by CMS of the four subset modifiers is intended to reduce improper use of modifier -59 while helping improve claims processing for providers.

CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

  • 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; and
  • XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service.

CMS states it will continue to recognize the -59 modifier, but notes that CPT instructions require the -59 modifier not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU}modifier for billing certain codes at high risk for incorrect billing.

The implementation date for this change is January 5, 2015. At this time, CMS will initially accept either a -59 modifier or a more selective -X{EPSU} modifier as correct coding, although CMS encourages rapid migration of providers to the more selective modifiers. However, CMS indicates modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.

View an MLN Matters article on the new HCPCS modifiers (pdf).

The frequent changes made to coding and billing rules create significant challenges for facilities working to collect what they deserve. Such challenges are just one of the many reasons more practices and ambulatory surgery centers (ASCs) are outsourcing their billing to a leading medical billing service provider such as PGM Billing. PGM has more than 30 years of practice and ASC medical billing experience. Contact PGM today to learn what they can do for your organization.


X