2015 Modifier 59 -sub coding updates

The –59 modifier is the most widely used HCPCS 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 -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.

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:

vDifferent encounters;

vDifferent anatomic sites;

vDistinct services.

The -59 modifier is

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

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

            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, the use of a service that is distinct because it does not overlap usual components of the main service.

           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.

As always, my staff will be available to assist you with any questions are concerns you may have.