According to CMS, they are establishing four new modifiers to define the subsets of the -59 modifier. -59 modifier is the most widely used Healthcare Common Procedure Coding System (HCPCS) modifier and can be broadly applied. CMS reports some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)" and associated with considerable abuse.  Modifier -59 has high levels of manual audit activity which leads to reviews, appeals and even civil fraud and abuse cases.  Additional information regarding CMS' view of how providers use modifier -59 is below.

FOUR NEW MODIFIERS - SUBSETS OF MODIFIER -59
CMS has defined 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 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. 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.

Visit CMS Modifiers for a copy of the August 15, 2014 Change Request 8863, Transmittal 1422 from CMS with more details.  The effective date is January 1, 2015 with an implementation date of January 5, 2015.

 

 

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