New CMS Modifiers Further Define Modifier 59

The Centers for Medicare & Medicaid Services (CMS) has established four new modifiers to define subsets of the commonly — but often mistakenly — used modifier 59.

 Modifier 59, the "distinct procedural service" indicator, is problematic because it applies to a wide variety of circumstances. Properly used according to Medicare National Correct Coding Initiative (NCCI) rules, it indicates that a code represents a service separate and distinct from another service with which it would usually be considered bundled. Modifier 59 can identify: 

  • A separate encounter (this usage is infrequent and usually correct, according to CMS);
  • A separate anatomic site (usage less common and less correctly applied); or
  • A distinct service (used commonly and often incorrectly, frequently overriding the NCCI edit in the exact circumstance for which CMS created the edit in the first place). 

CMS therefore has established four new modifiers, collectively called X{EPSU} modifiers, to define specific subsets of modifier 59:

  • 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.

TMA has expressed concerns to CMS about the short notice provided to physicians and a lack of clarity regarding the mandatory use of the new modifiers. Meanwhile, here are some tips:

  • CMS will continue to recognize the modifier 59 in many instances, but notes that CPT instructs coders not to use modifier 59 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. For example, a particular NCCI code pair may be identified as payable only with the XE separate encounter modifier but not the 59 or other X{EPSU} modifiers.
  • As a default, at this time CMS will initially accept either a modifier 59 or a more selective X{EPSU} modifier as correct coding.
  • Because the X{EPSU} modifiers are more selective versions of modifier 59, it would be incorrect to include both modifiers on the same line. Do not report both modifier 59 and the X modifier on the same line.
  • Medicare administrative contractors like Novitas Solutions also can require use of selective modifiers. Listen to Novitas' Medicare Insights Weekly-Part B podcast, episode 75, which discusses the new modifiers.
  • Also read CMS' MLN Matters No. MM8863 (PDF) about the new modifiers. Watch also for additional information from CMS as it becomes available.
  • TMA has asked CMS for guidance on how the use of these modifiers will affect Medicare claims that cross over to Medicaid and commercial health plans. Stay tuned for updates and clarification.

Bookmark TMA's Payer Resource Center for news and updates about Medicare and other payers. Need help with coding? Call on TMA Practice Consulting's certified professional coders and auditors to review your coding and medical record documentation to determine whether your practice is following payers' guidelines for appropriate billing. For more information about a Coding and Documentation Review for your practice, call (800) 523-8776 or email TMA Practice Consulting.  

Published Oct. 7, 2014

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