Friday, October 16, 2015

Specific Modifiers for Distinct Procedural Services

Provider Types Affected

This MLN Matters Article is intended for physicians, providers and suppliers submitting claim to Medicare Administrative Contractors (MACs) and Durable Medical Equipment (DME) MACs for services provided to Medicare beneficiaries.

Provider Action Needed
STOP-Impact to You

New coding requirement related to Healthcare Common Procedure Coding System (HCPCS) modifier - 59 could impact your reimbursement.

CAUTION-What You Need to Know

Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare & Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifiers, a modifier used to define a "Distinct Procedural Service".

GO-What You Need to Do

Make sure your billing staffs are aware of the coding modifier changes.


The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

CR8863 discussed changes to HCPCS modifier-59, a modifier which is used to define a "Distinct Procedural Service". Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The - 59 modifier is the most widely used HCPSC modifier. Modifier - 59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with the - 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:

•    Different encounters;
•    Different anatomic sites; and
•    Distinct services.

The - 59 modifier is

•    Infrequently (and usually correctly) used to identify a separate encounter;
•    Less commonly (and less correctly) used to define a separate anatomic site; and
•    More common only (and frequently incorrectly) used to define a distinct service.

The - 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU}modifiers) to define specific subsets of the 59-modifiers:

•    XE Separate Encounter, A Service That us 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, and

•    XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of the Main Services.

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. For example, a particular NCCI PTP code pair may be identified as payable only the - XR separate encounter modifier but not the - 59 or other - X{EPSU} modifier are more elective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a - 59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.

However, please note that the modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general - 59 modifier, when necessitated by local program integrity and compliance needs.

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