Practice Management Alert

Caution: Modifier 59 won’t be your CCI catch-all.

When you hear “Correct Coding Initiative (CCI)” or “bundled” you probably think of modifier 59 (Distinct procedural service).  Most coders know that modifier 59 can separate CCI edits, but it is not meant to be utilized solely for that reason. If you rely too heavily on what CMS describes as “the most widely used HCPCS modifier,” you are asking for an audit.

Good news: CMS intends to stop modifier 59 misuse by introducing four new modifiers to take its place in specific circumstances, and these modifiers may make your job a bit more straightforward. 

Review the Issues With 59

CMS says in Transmittal R1422 (issued on Aug. 15) that many providers misuse modifier 59 with CCI bundles, leading the modifier to be the source of a projected one-year error rate of $770 million. CMS points out the following three common reasons that people use modifier 59, along with the associated error odds, according to MLN Matters article MM8863, issued on Aug. 15:

• Infrequently used to identify a separate encounter, typically used correctly
• Less commonly utilized to define a separate anatomic site, less often used correctly
• Commonly used to define a distinct service, but frequently done so incorrectly.

Say Hello to “EPSU” Modifiers

In light of the problems that CMS has faced when dealing with modifier 59, CMS felt the need to find a solution. “The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place,” the MLN Matters article says. “CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.” 

To that end, CMS has debuted the following new modifiers, known as the “X(EPSU)” modifiers:

• 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).

“The new modifiers should not negatively affect claim success,” says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore. “It is just extra work for the coders and billers, thereby increasing costs to providers. If it does do it’s intended job, the further descriptors will only reduce reimbursement to fraudulent claims that should not have been paid anyways for providers who are following appropriate coding and billing rules. It may actually reduce the risk of audits when used correctly.”

Don’t Skip 59 Entirely

Although the new modifiers will replace modifier 59 in specific instances, CMS won’t cease accepting 59 in 2015. CMS will continue to recognize modifier 59, which does indicate that a code represents a service that is separate and distinct from another bundled service. The X(EPUS) modifiers are more selective versions of  modifier 59 to help clarify billing, so some procedures that are at high risk for incorrect billing will require one of the X(EPUS) modifiers. Either modifier 59 or X(EPUS) will be acceptable for payment purposes, but it would be incorrect to include both on one line.

Official guidance: “CMS will not stop recognizing the 59 modifier but notes that CPT® instructions state that the 59 modifier should not be used when a more descriptive modifier is available,” says the Transmittal, which has an effective date of Jan. 1, 2015. “CMS will continue to recognize the 59 modifier in many instances but may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing.”

“The transmittal said that these new modifiers do not cover all aspects when the 59 might be used so you can still use the 59 modifier if you think that you have a situation that is applicable to the 59 modifier but not applicable to these four alternatives,” says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CPCO, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Again, it makes you think and make sure you are meeting the definition and not just adding a 59 to get paid because the two codes are bundled.”

For instance, CMS is eventually going to institute edits that will allow the XE modifier to separate a specific CCI edit pair, but won’t accept modifier 59 or XU to separate that particular pair. As a way of easing into the new modifiers, CMS will initially accept either modifier 59 or the X(EPSU) modifier for a service, but “the rapid migration of providers to the more selective modifier is encouraged,” the MLN Matters article notes. However, MACs can start requiring the more specific modifiers in place of modifier 59 at their convenience, so keep an eye out for local requirements.

Keep in mind that CMS does not want you to play it safe and just add all of the modifiers to each CCI edit you’re trying to separate. Therefore, you can’t report both the 59 modifier and an X(EPSU) modifier on the same line item. 

Resource: To read the transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf. To read the MLN Matter article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf.

Stay tuned: Watch for further information about the new X(EPSU) modifiers in upcoming issues of Practice Management Alert.