The Centers for Medicare and Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”
Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.
Because it can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)”—it is the most widely used modifier.
The NCCI has Procedure to Procedure edits to prevent unbundling and consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code so it would be inappropriate to report it separately.
Separate reporting would trigger a separate payment and would constitute double billing. Modifiers are used to bypass edits when they are set by NCCI as optional edits.
CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows:
- 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.
CMS will not stop recognizing the -59 modifier, but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available.
CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific -X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.
The -X{EPSU} modifiers are more selective versions of the -59 modifier, so it would be incorrect to include both modifiers on the same line.
At this time CMS will initially accept either a -59 modifier or a more selective -X{EPSU} modifier as correct coding; although the rapid migration of providers to the more selective modifiers is encouraged.
However, these modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.