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Medicare Replaces Modifier 59

Medicare Replaces Modifier 59 February 5, 2015

Use of modifier 59 has been a long term compliance focus of the Office of Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and has been a frequent subject of many contractor audits.  All of these agencies have identified a high error rate related to the use of modifier 59 which has lead to a high volume of improper payments.  In an effort to improve compliance, on January 1, 2015, Medicare implemented four new modifiers to more descriptively identify the circumstances for which a provider is separately reporting a distinct procedural service.  The new 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 or structure.
  • XP (Separate Practitioner) – A service that is distinct because it was performed by a different practitioner.
  • XU (Unusual Non-Overlapping Service) – A service that is distinct because it does not overlap usual components of the main service.

CMS noted in their transmittal that they will not stop recognizing the modifier 59, but they refer to the CPT manual instructions which state that modifier 59 should not be used when a more descriptive modifier is available.  CMS also noted that contractors may selectively require the use of the new, more specific “X” modifiers in lieu of modifier 59.  Additionally, CMS is encouraging providers to make a rapid transition to the new “X” modifiers, which suggests they may soon deny claims reported with modifier 59.

We encourage providers to evaluate their modifier use.  The use of modifier 59 and/or the new “X” modifiers should be rare and the medical record documentation should clearly support the addition of these modifiers to a claim.  Providers should also ensure the new “X” modifiers have been added to their system and that coders have received education on the appropriate use of the new modifiers.

Our consulting staff includes professionals Certified in Healthcare Compliance (CHC) as well as certified coders.  We are available to provide assistance with evaluating billing compliance of these modifiers as well as providing customized education and training.

The CMS transmittal may be accessed at the following location: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf?utm_source=AIHC+newbaslt+Modifier+-59+ICD10+camp+ad+08%2F21+ALL+9pm&utm_campaign=BLAST+08%2F21+9pm+Modifier+59+ICD10+camp&utm_medium=email

DISCLAIMER:  This post contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations given is general and specific questions should be directed to professional counsel.

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