CMS Introduces Four New Modifiers in Lieu of Modifier 59
- By John Verhovshek
- In CMS
- August 26, 2014
- 30 Comments
The Centers for Medicare & Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, which is used to designate a “distinct procedural service.”
Modifier 59 is the most widely used HCPCS modifier: It is defined for use in a wide variety of circumstances, and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. This modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of modifier 59 and help to improve claims processing for providers.
Transmittal 1422, Change Request 8863 provides that CMS is establishing 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
Although CMS will continue to recognize modifier 59 in many instances, per CR8863:
CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS … may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP 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.
The implementation date for this change is Jan. 5, 2015. Initially, either modifier 59 or a more selective –X{EPSU} modifier will be accepted, although CMS has encouraged a rapid migration of providers to the more selective modifiers. For further instructions regarding this change check with your MAC.
Lynn Stuckert, LPN, CPC, CPMA, has 30 years of experience in large multi-specialty clinics and hospital systems as a nurse, chart auditor, educator, compliance manager and medical writer. Stuckert has held offices for AAPC’s City of Palms Chapter and the Health Management Association of Southwest Florida.
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WILL AAPC GIVE SOME EXAMPLES OF THESE ESPECIALLY XS AND XU. WHAT DO THEY MEAN BY STRUCTURE? WHAT IF YOU HAVE POLYPS REMOVED BY SNARE AND BIOPSY IN DIFFERENT AREAS OF THE COLON? WHICH WOULD YOU USE?
THANKS
Has any other payors implemented this or will ? such as Blue Cross or Blue Shield ? any confirmation yet?
when do this take place and will it take place on cpc exam
Per the CMS transmittal 1422 the effective date for the change is for dates of service 1-1-2015 (unless otherwise specified).
Will these new modifiers apply to facility APC coding?
XP will replace 76 and 77?
ridiculous, theres too many codes as it is
CORRECTION, 77
Will the codes be published in the new CPT 2015 editions? and are EHR vendors aware of this?
CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. So will CMS allow continued use of 59 if one of the four new X(EPSU) modifiers are not descriptive of the situation being reported?
What my other concern is the XE, what exactly do they mean by encounter? do they mean a separate service by date or diagnosis?
They are stating the 59 modifier will still be valid but they would prefer being more specific with these modifiers because of the abuse with the 59 modifier. i would really like a more descriptive response as to when these modifiers should be used for physical therapy.
Thank you
For modifier XP, a couple of examples of “different practioners” would be appreciated.
For XP, our practice is a good example since we offer both Medical Oncology services and Radiation Therapy. Patients may end up seeing both specialties on the same day. The XP would be used if they have an office visit with both the Medical Oncologist and the Radiation Oncologist on the same day.
Do you know of any webinars or other venue to learn more about X{EPSU} – other than contacting our MAC? We would like to learn as much as we can about X{EPSU} to help us in implementation, as they have a huge impact on my organization. Thank you.
Will there be any upcoming webinars/seminars related to this topic in the near future to educate providers on this change?
I just checked and these new modifiers are not in the CPT 2015. So, I also would like to know if there are any upcoming seminars/webinars prior to the implementation date of 1/2015 to instruct us on appropriate usage.
California’s MAC has a couple of free webinars scheduled on this topic
These modifiers are in the 2015 CPT book. If you look under Appendix A you will see under the description of Modifier 59 last line it tells you to go to a page (in 2015 Prof it is page 684). Unfortunately, there it does not have any detail info just the listing. Yes, there are seminars. Our office just had one a few weeks ago. Hopefully, the HCPCS book will be more detailed when it comes out. Or check out GOOGLE
I would like to see some examples of how to use these new modifiers. The descriptions are not very clear.
We’ll be running some articles in HEalthcare Business Monthly, and they’ll be on this site after they’re published.
I am just looking for examples of when to use the x modifers.
What X code would be used when the same CPT/HCPCS code includes more than one type of test? Example: Physicians ordered C3 and C4 together all the time. The CPT code for both is 86160…what X code should be assigned. The descriptions of the 4 new X codes makes no sense for this situation.
Has anyone heard who all will be using the new “X” codes, i.e., hospital outpatient depts., EDs, physicians, etc.?
UHC has posted information on the new “X” modifier in their January 2015 bulletin, page 27.
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/January_2015_Network_Bulletin.pdf
We just received the notice from UHC and the modifiers are explained very well. The way that I understand it CMS is implementing so I assume it will be across all insurances.
Is there training for this new modifier available through AAPC or somewhere else. We are in Kansas. Thanks for you help!
Anyone with GI experience who can help with GI coding for EGD (43239) plus Small Bowel Biopsy (44361) modifier application.
Are these codes to used in conjunction with 59 modifier or are they replacing it all together?
Should the XP modifier be used for every patient seen in the nursing home? My group is a specialty practice that services nursing homes. A resident typically could see more than one doctor a day, yet my doctors would not know that….so should the XP modifier be automatically added to every claim? Thank you.
does anyone know which modifier to use to bill medicare is to read a pulmonary function test?
Can someone please direct me to where I can find SPECIFIC examples of appropriate usage of the XS modifier is used. Particularly I cannot find documentation for the XS modifier when cardiac monitoring or Infusions/Injections are being done with other procedures.
Thanks