Health Information Management

Q&A: Should we hardcode modifier -59 for certain services?

APCs Insider, October 24, 2014

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Q: We are looking at hardcoding modifier -59 (distinct procedural service) to some line items in our charge description master (CDM) in order to facilitate getting our "discharged not final billed" (DNFB) down. Currently, we manually review every edit and situation and believe that in some circumstances the department can decide that the modifier is applicable and apply it via the chargemaster. Is this a common practice?
A: Hardcoding a modifier to the CDM means that the modifier is assigned to that charge item, and whenever that line item is charged, the modifier appears on the claim with the HCPCS code. Modifier -59 is designed to identify services that:
  • Occurred at separate encounters
  • Involved different anatomic sites
  • Were distinct in the specific scenario
There are several industry viewpoints regarding the application of modifier -59, each of which has some validity.  
Regardless of viewpoint, beginning in January 2015, it becomes a renewed subject for discussion. Transmittal 1422describes four new modifiers that are described as “subsets” of modifier -59. These modifiers will “selectively identify subsets of Distinct Procedural Services.” The modifiers are referred to collectively as -X{EPSU} modifiers and each has a specific definition designed to provide more insight on why the code pair is being reported together: 
  • -XE, separate encounter—a service that is distinct because it occurred during a separate encounter
  • -XP, separate practitioner—a service that is distinct because it was performed by a different practitioner
  • -XS, separate structure—a service that is distinct because it was performed on a separate organ/structure
  • -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 notes that, following CPT® guidelines, when one of these modifiers is more appropriate, coders should use the more specific modifier instead of modifier -59. CMS will continue to recognize modifier -59 in certain instances, but “may selectively require a more specific –X{EPSU} modifier for billing certain codes at high risk for incorrect billing.” Based on the information in the transmittal, certain code pairs will be reimbursed only when a specific subset modifier is reported, but not reimbursed when modifier -59 or one of the other subset modifiers is reported.
At the time of the transmittal being published, CMS expects to accept either modifier -59 or one of the -X{EPSU} modifiers, “although rapid migration of providers to the more selective modifiers is encouraged.” CMS will be implementing national edits and notes that Medicare contractors have the prerogative to require the use of the selective modifiers when they deem necessary for program integrity and compliance reasons.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.


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