The Centers for Medicare and Medicaid Services has made a significant change in the reporting of modifier -59, which will have considerable impact on medical coding in 2015. A new set of specific HCPCS modifiers has been introduced to selectively identify subsets of Distinct Procedural Services (modifier -59). This significant change implemented from January 5, 2015 was introduced as the modifier -59 was found to be abused more commonly due to the lack of specificity.
Issue with Modifier -59
This modifier is commonly known as the ‘Bundle Breaking Modifier.’ Though a number of bundling edits have been established through the National Correct Coding Initiative, you can break many of the bundles using this modifier. However, incorrect unbundling is a form of fragmentation and thus double billing that would result in overpayment. As per the 2013 CERT Report data, a projected $2.4 billion in MPFS payments were made for modifier -59, with a $320 million projected error rate while a projected $11 billion was billed for -59 modifier in facility payments with a projected error of $450 million. This proved that this modifier is abused more commonly and Medicare recognized that substantial federal savings would result by curbing the inappropriate use of this modifier.
According to the CMS, the major issue associated with this modifier is that it is defined for use in a wide variety of circumstances such as a use to identify different encounters, different anatomic sites, and distinct services. The CPT definition for modifier -59 is as follows:
59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
CMS believes more precise coding options coupled with increased education and selective editing is required for reducing the errors and has come up with four new HCPCS modifiers.
New HCPCS Modifiers
CMS established the following new 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
Correct Reporting of -59 and -X {EPSU} modifiers
CMS will continue to recognize modifier -59, but may selectively need a more specific X{EPSU} modifier for billing certain codes during high risk for incorrect billing. That is, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier, but not with the -59 or other -X {EPSU} modifiers. Since the -X {EPSU} modifiers are more selective versions of the -59 modifier, it is incorrect to include both modifiers on the same line.
The combination of alternative specific modifiers with a general less specific modifier can cause additional discrimination in case of reporting and editing. CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding as a default at this time even though the providers are encouraged to migrate to the more selective modifiers. However, these modifiers are valid ones even before national edits are in place. So, contractors can use selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.
Though CMS has recommended rapid migration to the use of specific modifiers, it is still not clear whether private payers will recognize the new modifiers. It is necessary to review informational updates from the respective payers and contact them individually for additional questions to determine this. Apart from that, you should constantly monitor changes in the National Correct Coding Initiative edit lists. With the support of professional medical billing and coding services, physicians can correctly use the new modifiers, avoid claim denials and receive accurate reimbursement.
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