Modifier -59 – A New Chapter of Guidance

Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC

Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) will be implementing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to help further define subsets of the -59 modifier.

Modifier 59 is appended to signify a distinct procedural service from other procedures or services performed within the same provider visit that would normally be considered bundled services. This modifier is utilized to identify a variety of coding situations, including different encounters & anatomic sites to distinct services. Because this modifier is appended in a variety of circumstances, it is often subject to incorrect usage; modifier 59 is often used as a primary way to bypass Medicare National Correct Coding Initiative (CCI) edits. CMS has also noted that the modifier -59 often overrides the CCI bundling edit in the same circumstance for which the modifier was originally created.

In an effort to reduce billing errors & improper use of modifier 59, CMS has introduced four subset modifiers (collectively referred to as –X {EPSU} modifiers);

• XE Separate encounter—Service that is distinct because it occurs during a separate encounter.
• XS Separate structure—Service that is distinct because it is performed on a separate organ/structure.
• XP Separate practitioner—A service that is distinct because it is 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.

CMS will continue to recognize the -59 modifier in 2015 but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. Per CR8863, 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 PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X {EPSU} modifiers.”
Be sure to check with your local MAC contractor & private insurances regarding the usage of the new -X {EPSU} modifiers; local Medicare contractors & private carriers can establish their own payment policies regarding the use of these new subsets.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf