Gastroenterology Coding Alert

Modifier 59 usage in its current form may be allowed until further notice. 

Many surgery practices have been getting busy or getting worried regarding when and how to implement the X{EPSU} modifiers, which CMS created to avoid overuse of modifier 59 (Distinct procedural service).

Absent specific CMS instruction, you may still be waiting, or you may be trying to follow some payer-specific advice about the modifiers. But now the CMS is advising practices to stick with 59 for the time being.

Background: Last summer, CMS announced that it was debuting four “X” modifiers to use as subsets of modifier 59.The X modifiers offer increased specificity to describe the circumstances that make your service “distinct,” and are defined as follows:

• 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 Finally Speaks

Several MACs followed up with advice on how to use the new modifiers, but CMS stayed mum, failing to offer examples or scenarios that describe how you should use them. On April 14, however, CMS reps finally addressed the issue during a CMS Open Door Forum, noting that the lack of advice was deliberate.

“In releasing the modifiers, we did not release instructions for the modifiers at that time the way CMS normally does, and there’s a specific reason for that,” said Dan Duvall, MD, chief medical officer with CMS’s Center for Program Integrity. 

“First of all, this was an initiative coming out of the Center for Program Integrity rather than the usual sources of most of the modifiers,” Duvall said. “Secondly, in releasing the modifiers, we specifically wanted the system maintainers and the external system designers — those people who design the software for your offices — to have time to make changes to incorporate those new modifiers into the systems before we started requiring their use.”

Practices, however, began growing impatient about the lack of national modifier instructions, which Duvall said will materialize “at some point in the future.” Until that time, he said, you should continue to lean on modifier 59 for your claims if you aren’t comfortable appending the X modifiers before CMS releases advice on how to use them.

Do this: “Since there is no reason for not continuing to use the 59 modifier, which is the current practice of most billing entities, there is no advantage to making the changes at this point of switching from the current practice of appropriately using the 59 modifier to using the new additional modifiers,” Duvall said. “So over the next number of months you can expect to at some point see an instruction from CMS that will talk about the use of the new modifiers and changes and any edits that may be appropriate… so until we publish something, it is acceptable to continue to use the 59 modifier exactly as you have been using it in the past.”

When a caller to the forum asked for an example of how to use the XU modifier, Duvall told her, “From our standpoint there is no benefit to using it over 59.”