Modifier -59 Could Impact Your Reimbursement - New Coding Requirements!

Centers for Medicare & Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”

Be sure your billing staff is aware of the modifier changes!

The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:

• Different encounters;
• Different anatomic sites; and
• Distinct services.

 The -59 modifier is:

• Infrequently (and usually correctly) used to identify a separate encounter;

• Less commonly (and less correctly) used to define a separate anatomic site; and

• More commonly (and frequently incorrectly) used to define a distinct service.

The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.

CR8863 provides that 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 will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should 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.

For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.

However, please note that these modifiers are valid even before National edits are in place. MACs 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.

 EFFECTIVE DATE: January 1, 2015

*Unless otherwise specified, the effective date is the date of service.


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf

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