Medicare’s most popular modifier is getting a makeover.
Modifier -59 defines a ‘distinct procedural service.’ Medical billing experts use modifier -59 to bill separately for a procedure typically bundled together with other services. “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,” according to a CMS Medicare Learning Network News Flash.
So starting January 2015, CMS breaks Modifier 59 into 4 new HCPCS subset modifiers. Their goals include reducing incorrect use and the potential for Medicare overpayment to providers.
CMS states that providers and medical billing companies should replace modifier -59 with:
XE – Separate Encounter to code a distinct service that occurred during a separate encounter;
XS – Separate Structure to code a distinct service performed on a separate organ or structure;
XP – Separate Practitioner to code a distinct service performed by a different practitioner;
XU – Unusual Non-Overlapping Service to code for a distinct service that does not overlap with the usual components of the main service.
“This means providers will now need to be specific as to why they are utilizing the new modifier 59 replacement codes, and they must show proof that it is not being used as a last resort for payer reimbursement,” says CareCloud billing expert Dynah Cociffi.
Georgina Valdez, another CareCloud billing expert, adds: “In addition, providers would need to ensure that their medical documentation is vital and essential to support medical necessity, and this information must be well documented in the patients’ medical records.”
For now, CMS will continue to accept Modifier -59 or one of the more selective modifiers “although the rapid migration of providers to the more selective modifiers is encouraged.” One possible exception: the agency may only recognize the new modifiers for codes associated with a higher risk for incorrect billing.
See the CMS Manual System One Time Notification for more information on the new modifiers to replace Modifier 59.
