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Medicare plans new coding modifiers for 2015

David Twiddy
August 27, 2014

The Centers for Medicare & Medicaid Services (CMS) recently announced that it is creating four new Healthcare Common Procedure Coding System (HCPCS) modifiers that will further refine the popular -59 modifier.

Adding a modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Family physicians and others often use it to override edits found in Medicare’s National Correct Coding Initiative (NCCI). In fact, according to CMS, -59 is the most widely used modifier in the HCPCS.

That popularity is partly because, as currently defined, the -59 modifier can be used in a wide variety of circumstances, such as identifying different encounters, different anatomic sites, or distinct services. But physicians aren't always clear on why they're using the modifier, and, from CMS’s perspective, that usage is not always correct. CMS believes it can reduce the incorrect use of modifier -59 – and the subsequent Medicare overpayments – with a combination of more precise coding options, increased education, and selective editing.

As noted in the latest Medicare Learning Network Matters article, CMS on Jan. 1, 2015, will establish four new HCPCS modifiers to define specific subsets of the -59 modifier. They are referred to collectively as -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, and
• XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

For the time being, CMS will continue to accept the -59 modifier. But don't expect that to last indefinitely as the agency notes that, under CPT, physicians should not use the -59 modifier when a more descriptive modifier is available. That means CMS may decide to require a more specific - X{EPSU} modifier for billing certain codes it believes are more likely to generate billing errors. For example, CMS may designate a particular NCCI code pair as payable only with the –XE (Separate Encounter) modifier and not the -59 or other -X{EPSU} modifiers. So be prepared to be more selective in your use of modifiers with Medicare in the near future.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted on Aug 27, 2014 by David Twiddy

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