In mid-August, the Centers for Medicare & Medicaid Services (CMS) released a Change Request, CR8863, informing physician practices and their billing staff that four new Healthcare Common Procedure Coding System (HCPCS) modifiers are to be reported instead of modifier -59 when reporting subset definitions of “Distinct Procedural Services.” The new modifiers are effective January 1, 2015, and could potentially affect your reimbursement. It is important to ensure coder and biller education occurs prior to the effective date, and all software impacting the use of these new modifiers has been updated.
New modifiers released to further define Distinct Procedural Services
The four new HCPCS modifiers (“–X {EPSU},” collectively) that more granularly define subsets of Distinct Procedural Services (-59 modifier) are as follows from CMS’ CR8863:
- “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”
Modifier -59 has been diversely used, often abused
Currently, the -59 modifier is the most commonly reported HCPCS modifier. This modifier is known for being reported incorrectly, which has resulted in numerous payer audits. Additionally, use, or improper use, of this modifier has been associated with several civil fraud and abuse cases. The -59 modifier allows the reporter to bypass National Correct Coding Initiative (NCCI) bundling edits, which will result in an overpayment if not applied correctly. Modifier -59 identifies scenarios when the second procedure reported defines a subset of the work of another procedure that is being billed during the same encounter. However, the use of the -59 modifier should only be used when the second procedure constitutes a distinct service. Separate payment is allowed when the documentation supports that the second procedure is:
- A different encounter
- A different anatomic site
- A separate incision/excision
- A separate lesion
- A separate injury
Due to the diverse use of this modifier, it is common to have confusion and/or lack of education among coders and payers. Many coders and billers do not realize the financial impact this modifier can have on physician reimbursement. Claim scrubber edits and NCCI features are very beneficial tools to enhance your practice management systems and to ensure that your claims are accurate prior to submission. Therefore, if your practice utilizes these tools, it is imperative the coder or biller understands the scrubber or NCCI notifications and the correct application of these new modifiers.
What Now
CMS will continue to recognize the -59 modifier. However, coders should continue to follow Current Procedural Terminology (CPT) instructions which state that the -59 modifier should not be used when a more descriptive modifier is available. The -59 modifier should never be used with an –X {EPSU} modifier on the same claim line. CMS may require certain –X {EPSU} modifiers for certain codes it considers high-risk for improper reporting of the -59 modifier.
CMS believes adding more specific modifiers, coupled with increased education and selective editing, will reduce the errors associated with modifier -59 overpayments. However, we anticipate further clarification from CMS on the use of the new modifiers and potential push-back from the provider community. We know a separate encounter and a separate structure are currently defined for reporting the -59 modifier. However, the -59 modifier is not required when another practitioner is performing the second service. Therefore, adding the -XP modifier is an additional reporting step which is not currently required.
Further, given the broad description assigned to the –XU modifier, providers and coders are likely to have many questions. The –XU modifier is the most confusing and non-descript of the four. Stay tuned for additional industry guidance on this subset modifier.
Conclusion
The newly released HCPCS modifiers may add to confusion and diverse interpretation. Providers and coders should be prepared to be more selective when reporting modifiers on Medicare claims by January 1. Monitor Medicare and other payers for further clarifications, education, and usage requirements.
View the CMS Change Request CR8863 here.
If you have questions about the new HCPCS modifiers or would like to request information about coder and biller training, contact the experts listed below at PYA, (800) 270-9629.
