Article By Heidi Stout, CPC, COSC, CCS-P
In an effort to reduce inappropriate claim payments due to incorrect use of modifier 59, The Centers for Medicare and Medicaid Services (CMS) will roll out four new HCPCS modifiers to describe specific circumstances when it is appropriate to override a CCI edit. These -X modifiers become effective on January 1, 2015.
The new –X modifier are:
- XE – Separate Encounter. Used to describe services that are separate because they take place during separate encounters
- XS – Separate Structure. Used to describe services that are separate because they are performed on different anatomic organs, structures or sites
- XP – Separate Practitioner. Used to describe services that are distinct because they are performed by different practitioners.
- XU – Unusual Non-overlapping Service. Used to describe services that are distinct because they do not overlap the usual components of the main service.
CMS has indicated that they will continue to recognize the -59 modifier in many instances; however, a more specific -X modifier may be required for certain code pairs that CMS has identified as being high risk for incorrect separate reporting. For example, an NCCI code pair may be identified as payable only with the -XS modifier indicating that the procedures were performed on separate structures, but not the -59 or other –X modifiers. CMS has stated that because the –X modifiers are more specific versions of the -59 modifier it would be incorrect to include both modifiers on the same line. When the modifier specific –X modifier describes the circumstances for reporting both codes it should be reported in lieu of modifier -59.
For more information on the Medicare modifier 59 replacement modifiers, please visit the following sites.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
