Health Information Management

CMS introduces major changes for modifier -59 use

APCs Insider, August 22, 2014

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By Steven Andrews, Editor
CMS is introducing four new HCPCS modifiers to define subsets of modifier -59 (distinct procedural service), the most frequently used modifier, in a move that could add considerable administrative work for providers.
"The impetus behind this is clear—there is a strong feeling by CMS that the use of this modifier is being abused," says Jugna Shah, MPH, president and founder of Nimitt Consulting. "Specifically, CMS’ belief is that providers are using it to bypass NCCI edits when they shouldn’t."
In MLN Matters® MM8863, which outlines the changes, CMS says modifier -59 is:
  • Infrequently (and usually correctly) used to identify a separate encounter
  • Less commonly (and less correctly) used to define a separate anatomic site
  • More commonly (and frequently incorrectly) used to define a distinct service
The four new modifiers, referred to collectively as the -X{EPSU} modifiers, are:
  • -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
"The agency definitely wants to know what providers tend to use modifier – 59 for which is why its released the four new modifiers," Shah says. "Starting next year, when providers begin using the new modifiers, the agency will clearly be able to see the reason for the use and as a result we may begin to see even more specific edits around which modifiers can go with which codes."
CMS isn't completely abolishing modifier -59, even though these new modifiers will be effective as of January 1, 2015. According to CMS, the agency will continue to recognize modifier -59, but reminds providers that CPT® instructions state that modifier -59 should not be used when a more descriptive modifier is available.
But that's not the only challenge providers will face with using these new modifiers.
"CMS says that even before it might create national edits around these modifiers, contractors are not prohibited from requiring the use of selective modifiers in lieu of modifier -59," says Shah. "In other words, local contractors may begin creating edits long before CMS does. Providers are going to have to be very vigilant."

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