Health Information Management

CMS’ latest modifier -59 update offers little guidance for providers

APCs Insider, February 6, 2015

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By Steven Andrews
 
After CMS announced four new, more specific replacements for modifier -59 (distinct procedural service) in August, providers have been clamoring for more guidance and examples to help them understand how and when to apply them.
 
Unfortunately, CMS' late January update in MLN Matters® article SE1503 offers little new information to providers, instead simply instructing them that modifier -59 can continue to be used after January 1 in all instances it was previously correctly applied.
 
The August release was simply "to inform system developers that healthcare systems would need to accommodate the new modifiers," according to CMS. While it's good that CMS didn't finalize these changes without giving providers time to prepare, the early release does seem unusual for the agency.
 
Providers typically only have 60 days from the release of the OPPS final rule to implement a variety of finalized regulations and modifiers that could have extensive operational or financial impacts.
 
The lack of guidance or examples in the initial release left providers wondering just how they should correctly append these new modifiers. In the August release, CMS defined what it's calling the –X{EPSU} modifiers as:
  • -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, a service that is distinct because it does not overlap usual components of the main service
Some of them appear self-explanatory, such as the –XP modifier to note services performed by separate practitioners. However, many providers have questioned how to use the –XU modifier, since CMS hasn't specifically defined when a service can be determined to be "unusual" and "non-overlapping."
 
Even modifiers that may seem obvious, such as –XS, will require further clarification from CMS. For example, Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota, questioned whether providers could use this modifier to report two initial drug administration codes. As of yet, CMS has not clarified whether a "separate structure" means a separate drug administration site.
 
CMS' latest release makes it clear that additional guidance and education on how to use these new modifiers will be released before CMS puts edits in place or conducts audits.
 
Providers who have identified codes or services that may require these more specific modifiers but are unsure about their applicability are encouraged to send detailed questions to NCCIPTPMUE@cms.hhs.gov.



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