Wednesday, August 26, 2015

Modifier 59 and New Modifiers XE, XS, XP, XU with example

The Medicare National Correct Coding Initiative (NCCI) * includes edits that define when two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together.

 A Correct Coding Modifier Indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.

One function of these edits is to prevent payment for codes that report overlapping services except in instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

The CPT Manual defines modifier 59 as a Distinct Procedural Service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Evaluation and Management (E/M) services performed on the same day.

 Modifier 59 identifies procedures/services, other than E/M services and radiation treatment management, which are not normally reported together, but are appropriate under the circumstances.

Documentation must support:
a different session,
different procedure or surgery,
different site or organ system,
separate incision/excision,
separate lesion,
or separate injury (or area of injury in extensive injuries)

Note: When another already established modifier is appropriate, report it instead of modifier 59. Use modifier 59 only if no other descriptive modifier is available.

Do not report modifier 59 or other NCCI-associated modifiers to bypass an edit unless documentation in the medical record supports its use.

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported.

Modifiers (collectively referred to as -X {EPSU} modifiers) are defined as follows:

XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.

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”

Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, you may begin using them for claims with dates of service on or after January 1, 2015.

Note: You have the option to continue using modifier 59 in any instance in which it was correctly used prior to January 1, 2015. CMS' additional guidance and education as to the appropriate use of the new -X {EPSU} modifiers is forthcoming.

Until CMS provides official guidance, Novitas offers the following suggestions for the use of the -X {EPSU} modifiers, should you decide to use them.

As a reminder, your medical documentation must support the use of modifiers.


The examples below are from the Centers for Medicare & Medicaid Services (CMS) Modifier 59 article * along with Novitas Solutions' suggestions for the optional use of modifiers XE, XS, XP, and XU beginning January 1, 2015.

Common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day, and cannot be described by one of the more specific anatomic modifiers, such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

Example 1
17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratosis) other than skin tags or cutaneous vascular proliferative lesions; first lesion

11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Modifier 59 may be reported with 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier does not apply.

If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used.

Modifier 59 is reported for different anatomic sites during the same encounter only when procedures, not ordinarily performed or encountered on the same day, are performed on different organs, different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

Example 2

47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Modifier 59 should not be reported with 76942 if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure.

Modifier 59 may be reported with 76942 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure

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