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CMS Defines New Modifiers as a Subset of -59

Female surgeon

Effective January 1, 2015, the Centers for Medicare and 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.”

Currently, providers can use the -59 modifier to indicate that a service usually considered bundled within another code was performed as separate and distinct from that other code. The problem with the -59 modifier, however, is that it applied in such a wide variety of circumstances, including the following:

  • To identify a separate encounter—used infrequently and usually correctly;
  • To define a separate anatomic site—used less commonly and often problematically;
  • To define a distinct service—used commonly and frequently overrode the edit in the exact circumstance for which CMS created the edit in the first place.

According to CMS, because the -59 modifier could be so broadly applied, some providers incorrectly considered it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI).” It is the most widely used modifier and also is associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals and even civil fraud and abuse cases. The four new, more precise modifiers, coupled with increased education and selective editing, should reduce the errors associated with frequent overpayments, according to CMS.

The four new HCPCS modifiers used to selectively identify subsets of Distinct Procedural Services (-59 modifier) are as follows:

  • 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
  • XU Unusual Non-Overlapping Service—The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. A few things to note when using any of the five Distinct Procedural Services Modifiers (-59 or -X{EPSU}):

  • CMS will not stop recognizing the -59 modifier although CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available.
  • CMS will continue to recognize the -59 modifier in many instances but 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.
  • 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.
  • The -X{EPSU} 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.

For more information, review the “CMS MLN Matters MM8863” released on August 15, 2014.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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