New HCPCS Modifiers Define Subsets of the 59 Modifier


By Jose Lopez, Senior Consultant, The Verden Group

As of January 1, 2015 the Centers for Medicare and Medicaid Services (CMS) established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier. The Modifier -59, which is used to designate a “distinct procedural service”, is the most widely used HCPCS modifier. It is defined for use in a wide variety of circumstances and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. In addition, this modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of Modifier -59 and help to improve claims processing for providers. The new modifiers (referred to collectively as -X{EPSU} modifiers) are:

  • 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 modifier -59 but may selectively require a more specific -X{EPSU} modifier for billing certain codes that are at high risk for incorrect billing. When a specific –X modifier describes the circumstances for reporting both codes it should be reported in lieu of modifier -59. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X {EPSU} modifiers are more selective versions of modifier -59, so it would be incorrect to include both modifiers on the same line. 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. For further instructions and implementation of the HCPCS Modifiers -X{EPSU}, check with your Medicare Administrative Contractors (MACs) or Private Payers.

CMS Resources:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf

www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

The American Academy of Pediatrics Update on Private Payer Implementation of HCPCS Modifiers -X{EPSU}:

www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Payer-Implementation-of-HCPCS-Modifiers.aspx

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