Learn about changes related to CPT Modifier 59 reimbursement and use guidelines under Distinct Procedural Service, effective from January 2015.

Important CPT Modifier 59 changes are coming one of the frequently used and misused modifier for Medicare reimbursement of CPT Codes in Acupuncture, Breast Biopsies, Physical Therapy, Radiology, Surgery and other medical practices.

On August 15, 2014 CMS released the final ruling for the appropriate Modifier 59 use and the changes that will take effect on January 1, 2015. It is critical that all coders and providers be made aware of the changes to the utilization of Modifier 59 (Distinct Procedural Service) that will go into effect starting from 2015.

Transmittal 1422, CR8863 details new modifiers to be used in place of modifier 59. The new modifiers will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers.

CPT Modifier 59 changes 2015 under Distinct Procedural Service

Studies have shown that the modifier 59 is both commonly used and commonly abused. According to the 2013 CERT report $2.4 billion was paid on claims containing modifier 59 with a projected error rate of $450 million USD. The error rate is not exclusively attributed to modifier 59, but if only 10% of those found to be in error were due to the modifier 59, that would represent a $45 million damage.

CPT Modifier 59 changes 2015 under Distinct Procedural Service

CMS has established new HCPCS modifiers to define subsets of modifier 59 which was previously used to define a "Distinct Procedural Service" CMS will continue to recognize modifier 59.

However due to the over utilization of Modifier 59, it should not be used beyond December 31, 2014. As a default, 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.

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.

CPT Modifier 59 Replacement Use

Therefore, our recommendation for all providers, coders and medical billing companies is to prepare to replace utilization of Modifier 59 with the distinctive descriptors as follows:
  • XE Separate Encounter: Service That Is Distinct Because It Occurred During A Separate Encounter
  • XS Separate Structure: Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
  • XP Separate Practitioner: Service That Is Distinct Because It Was Performed By A Different Practitioner
  • XU Unusual Non-Overlapping Svc: Use Of A Service That Is Distinct Because It Does Not Overlap usual components of the main service
These modifiers, are referred to as -X{EPSU} modifiers, and define specific subsets of the -59 modifier. 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.

CPT Modifier 59 Reimbursement Guidelines

To prepare and work well with CPT Modifier 59 changes 2015 under Distinct Procedural Service, we recommend the following steps to be taken:
  1. Always use the subset more descriptive Modifier EPSU’s. 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.

  2. All Medical Billing Practices should monitor the use of modifier 59 to ensure that it is currently being utilized appropriately.

  3. All Medical Billing Practice Managers should check with their medical coder or medical billers to insure they are prepared for this modifier 59 alteration.

  4. All Medical Billing and Coding Specialist should inform their providers. Make sure that there are no defaults set up in their Practice Management Software System, that automatically default modifier 59.

  5. Ensure the proper documentation of any distinct service.

Happy Coding! and keep visiting us to stay on top of all the continuing Medical Billing and Coding updates and changes.

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