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Medical Coding News Archives

New Modifiers Aim to Reduce Modifier 59 Errors

 
October 23, 2014:

The Centers for Medicare and Medicaid Services (CMS) has created four new HCPCS modifiers in an effort to reduce the erroneous use of modifier 59 to bypass edits under the National Correct Coding Initiative. Misuse of modifier 59 to identify distinct services has been estimated to cost Medicare $77 million per year in overpayments.

Modifier 59 is defined 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. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

CMS Transmittal 1422, dated August 15, 2014, defines the new modifiers:

  • XE Separate encounter, a service that is distinct becauase 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

The X{EPSU} modifiers become effective January 1, 2015; CMS will accept either modifier 59 or modifiers X{ESPU} as correct until providers get up to speed with the new modifiers. At that point, the agency will still recognize modifier 59 for many codes, but it might require one of the X{ESPU} modifiers for codes frequently reported incorrectly. For example, a code pair might be specified as payable only when modifier XE is appended. Of course, Medicare administrative contractors can require the more selective modifiers even before national edits are in place to meet their local program integrity and compliance needs.

CMS explains that modifier 59 has been problematic because it can be used in widely different circumstances to describe distinct services and different encounters and anatomic sites. The agency notes that many of the errors occur, in particular, when the modifier identifies separate anatomic sites.

For instance, if a retinal lesion is destroyed via photocoagulation (code 67210) during the same session that a choroidal lesion is destroyed, using the same method (67220), the latter code should not be reported. These are not considered separate anatomic sites because the retina and choroid are contiguous structures of the same organ. In the past, providers might have incorrectly appended modifier 59 to code 67220, thinking the choroid qualified as a “different site,” though not a different organ system. Of the new modifiers, the closest one to describe the procedure would be XS, but its description specifies that each procedure must have been performed on “a separate organ/structure,” making it clear that the retinal and choroidal photocoagulations should not be reported together, even with a modifier.

The high error rate with modifier 59 has been known for quite some time. A 2005 Office of Inspector General Report noted that, in fiscal year 2003, 40 percent of code pairs with modifier 59 were miscoded, costing Medicare $59 million in improper payments. Various efforts since then to correct the misuse have had little effect. CMS hopes that these new modifiers will solve the problem once and for all.

 

 
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