Modifier 59 (Distinct Procedural Service) is described by the Centers for Medicare and Medicaid Services (CMS) as the most widely used HCPCS modifier. In its August 15, 2014 Transmittal R1422, CMS contends that there are three common reasons that modifier 59 is used:
• Identify a separate session or encounter
• Define a separate anatomic site
• Indicate a distinct service
This modifier is charged with being used most-frequently to override the National Correct Coding Initiative’s bundling edits which CMS contends are often done incorrectly. In an effort to reduce associated errors and improve billing patterns, CMS is presenting four new ‘subset’ modifiers effective January 1, 2015.
- 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 continue to accept modifier 59 in 2015 but is encouraging providers to begin utilizing these more selective “X(EPSU)” modifiers in its place when appropriate. Ultimately, it is expected that CMS will develop national edits around these new modifiers; however, local Medicare contractors (MACS) can establish their own requirements for the use of these modifiers as well as 59.
It is unknown at this time if commercial insurance carriers will accept the new X(EPSU) modifiers come January. APS will continue to monitor industry guidance and provide updates as they become available.
