Back in September, we told you about the Centers for Medicare & Medicaid Services establishing new HCPCS modifiers to define specific subsets of the -59 modifier. These new modifiers went into effect on January 1, and had an implementation date of January 5.

To summarize:

  • The introduction of the subset modifiers is intended to reduce improper use of modifier -59 while helping improve claims processing for providers.
  • There are four subset modifiers: -XE separate encounter modifier (for a service that is distinct because it occurred during a separate encounter); -XS separate structure modifier (for a service that is distinct because it was performed on a separate organ/structure); – XP separate practitioner modifier (for a service that is distinct because it was performed by a different practitioner); and -XU unusual non-overlapping service modifier (for the use of a service that is distinct because it does not overlap usual components of the main service).
  • These four new HCPCS modifiers are referred to collectively as -X{EPSU} modifiers.
  • CMS 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.
  • CMS may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing.

The official instruction on this change issued to your MAC, Change Request 8863, is available by clicking here (pdf).

Using modifiers properly is one of the most difficult aspects of coding. Not only is it challenging to know when to use a modifier, but the rules about modifiers change regularly and may be followed differently from one payer to another. Improper use of modifiers can lead to denied claims, and modifier -59 is associated with considerable abuse and high levels of manual audit activity. This leads to reviews, appeals and even civil fraud and abuse cases.

To help ensure your practice does not encounter such a challenges with modifier use, consider outsourcing your billing to PGM Billing. PGM is a leading provider of doctors billing services, with more than 30 years of experience in many specialties across multiple facility types. Contact PGM to find out why the use of its electronic medical billing services can make sure you receive proper compensation for services rendered.