New modifiers physicians need to know for 2015

December 3, 2014

Learn about the new, more specific subsets of modifier 59

Question: I recently came across information saying that new modifiers will replace Modifier -59 in 2015. Is this true?

According to the 2013 Comprehensive Error Rate Testing (CERT) Report data, a projected $2.4 Billion in Medicare Physician Fee Schedule (MPFS) payments were made on lines with Modifier -59, with a $320 million projected error rate.

The Centers for Medicare and Medicaid Services (CMS) considers Modifier -59 to be the most widely used Healthcare Common Procedure Coding System (HCPCS) modifier because it is defined for use in a wide variety of circumstances.  Since CERT findings show a widespread misuse of Modifier -59, CMS reiterated in August that the -59 modifier is used to define a “distinct procedural service.” Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.  

Additionally, CMS reports that some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)” and thus is associated with considerable abuse.  Modifier -59 has high levels of manual audit activity, which leads to reviews, appeals and even civil fraud and abuse cases.  

Effective January 1, 2015, CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

  • Modifier XE-separate encounter: A service that is distinct because it occurred during a separate encounter.

  • Modifier XS-separate structure: A service that is distinct because it was performed on a separate organ/structure.

  • Modifier XP-Separate Practitioner: A service that is distinct because it was performed by a different practitioner.

  • Modifier  XU-Unusual Non-Overlapping Service: A service that is distinct because it does not overlap usual components of the main service.

These modifiers are valid even before national edits are in place.  CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. 

While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing.

Why the new subset to Modifier -59? CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment. The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances.

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.