X{EPSU} Modifiers

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the 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. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing. 

CR8863 discusses changes to HCPCS Modifier 59, a modifier which is used to define a “Distinct Procedural Service.” Modifier 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. 

Modifier 59 is the most widely used HCPCS modifier. Modifier 59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases. 

The primary issue associated with Modifier 59 is that it is defined for use in a wide variety of circumstances, such as to identify: i) Different encounters; ii) Different anatomic sites; and iii) Distinct services.

Modifier 59 is:

Infrequently (and usually correctly) used to identify a separate encounter; 
Less commonly (and less correctly) used to define a separate anatomic site; and 
More commonly (and frequently incorrectly) used to define a distinct service. 

Modifier 59 often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment. 

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as –X{EPSU} modifiers) to define specific subsets of modifier 59: 

Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter, 

Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure, 

Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and 

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 continue to recognize modifier 59, but notes that Current Procedural Terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. While CMS will continue to recognize the modifier 59 in many instances, it 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 modifier 59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the modifier 59 so it would be incorrect to include both modifiers on the same line. The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a modifier 59 or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. 

However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general modifier 59, when necessitated by local program integrity and compliance needs. 

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf

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