Changes on the Horizon for Modifier -59

CMS has published Change Request #CR 8863 and MLN Matters MM8863 which instructs providers that four new HCPCS modifiers have been created as subsets of the -59 modifier (Distinct Procedural Service). These new modifiers become effective January 1, 2015.

The National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and facilities. HCPCS modifier -59 is used to define a Distinct Procedural Service when there are two or more procedures performed on the same date with an NCCI edit in place, but for specific circumstances the provider has determined both are appropriate to report. The -59 modifier is attached to the second code (component of the comprehensive code) per the NCCI PTP edit to indicate to the payer the services performed meet the definition of separate and distinct.

The Modifier -59 has long been identified as the most overused and abused modifier, as it can be incorrectly reported to bypass the NCCI edits.

The CPT Manual defines modifier -59 as follows:

"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 (Evaluation and Management) 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."

The new HCPCS modifiers were developed to selectively identify subsets of Distinct Procedural Services (modifier -59), which will allow a better description of the reason the provider considers the procedure to be separate and distinct. They are as follow:

• 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; however, they do note that CPT instructions state 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 assigning certain codes at high risk for incorrect billing. The -X (EPSU) modifiers are more specific versions of the -59 modifier, so it would be incorrect to include both modifiers on the same line. CMS will initially accept either a -59 modifier or a more selective -X (ESPU) modifier as correct coding; however, they have stated they expect a rapid migration to the -X (EPSU) modifiers.

Following are examples which we anticipate will explain the use of the new modifiers; however, we do wish to note CMS has not published specific examples.  

• XE - Separate Encounter: The patient receives an outpatient infusion of antibiotics (CPT code 96365) at 8:00 AM, leaves the facility and returns at 8:00 PM for another infusion of the antibiotics. The second line item 96365 would require the -XE modifier.
   
• XS - Separate Structure: A skin lesion of the arm was destroyed via laser surgery and reported with CPT code 17000 (Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); and another lesion is biopsied on the leg and reported with CPT code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane including simple closure, unless otherwise listed; single lesion). CPT code 11100 would require the modifier - XS.  
   
• XP - Separate Practitioner (for physician reporting): A laparoscopic hernia repair (CPT code 49650) was performed in the morning by surgeon A; later in the day the patient developed acute abdominal pain and a laparoscopic appendectomy (CPT code 44970) was performed by surgeon B. The -XP modifier would be applied to CPT code 44970. 
    
• XU - Unusual non-overlapping service: Two separate lesions are present that are within the same code set, and are excised separately - i.e. a 4 cm. lipoma is excised on the upper thigh (CPT code 27337 - excision tumor soft tissue thigh/knee subcutaneous greater than 3 cm) and a separate lipoma excised on the lower leg (CPT code 27327 - excision tumor soft tissue thigh/knee subcutaneous less than 3 cm). The -XU modifier would be applied to code 27327.

We recommend facilities and providers watch for further updates from CMS and their interpretation of the -X (EPSU) modifiers.

For more information, please contact Susan Roehl or your Eide Bailly representative.