In addition to unleashing all the 2015 PQRS changes, the Centers for Medicare and Medicaid Services (CMS) decided to throw us another curveball by introducing the following four HCPCS modifiers—called the X{EPSU} modifiers—to “define specific subsets” of the 59 modifier.

  1. XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
  2. XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
  3. XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
  4. XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

Download your modifier 59 decision chart.

Enter your email address below, and we’ll send you a super-simple flow chart to help you decide whether it’s appropriate to use modifier 59 in any given billing situation.

Please enable JavaScript to submit form.

How I Met Your 59 Modifier

So, why did CMS decide to create the new subsets? (Don’t worry; it won’t take nine years for this explanation). Simply put: the 59 modifier causes more confusion and anxiety than waking up next to a pineapple. It’s meant to describe a distinct procedural service, but because the 59 modifier is so widely used and so broadly defined, providers wind up using it to:

  • Infrequently (and most of the time, correctly), identify a separate encounter.
  • Less commonly (and less correctly), define a separate anatomic site.
  • More commonly (and often incorrectly), define a distinct service.

In fact, current 59 modifier use is so wonky that it’s often “associated with considerable abuse and high levels of manual audit activity,” reported CMS in an MLN Matters release, which has landed some providers in hot water via “reviews, appeals, and even civil fraud and abuse cases.” Plus, the 59 modifier “often overrides the edit in the exact circumstance for which CMS created it in the first place.” The new subsets, however, allow for greater specificity, which CMS believes will reduce errors and misuse.

But that’s not the end of the story.

The Plot Twist

In a recent statement, CMS announced that it would allow “the continued use of modifier 59 after January 1, 2015 [...] in any instance in which it was correctly used prior to January 1, 2015.” So, while CMS will continue “to introduce the modifiers in a gradual and controlled fashion,” for the moment, you can keep using modifier 59 the same way you’ve been using it (provided you’ve been using it correctly) until CMS provides further guidance. Montero Therapy Services offers further clarification in this blog post, stating that the “APTA reported that per CMS, therapists could ‘keep on using Modifier 59 in reimbursement claims to indicate that a HCPCS represents a service that is separate and distinct from another service to which it is paired under the Correct Coding Initiative (CCI) program.’”

What Happens Next?

Though the new subsets aren’t likely to inspire a cult following, you’ll want to pay close attention as updates come down the CMS pike, because sooner or later, CMS says it “will identify situations in which a specific modifier will be required and will publish specific guidance before implementing edits or audits.” Until then, keep on keepin’ on—but make sure you and your billing staff are aware of the changes as they come.

Unsure if you’re using the 59 modifier correctly? Check out our blog post or our open-forum modifier webinar for more information.

WebPT + Billing Software - Regular BannerWebPT + Billing Software - Small Banner
  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. Questions related to: • WebPT • Modifier 59 • Other Modifiers • Coding • ICD-10 • …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • 9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs Image

    webinarSep 8, 2016

    9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs

    To say that Medicare regulations are confusing is an understatement. But, it’s not just the barely-readable government gobbledygook that throws providers for a loop; it’s also the fact that the rules are always changing. If you treat Medicare patients, we’re willing to bet you’ve been tripped up by at least one of these common misconceptions—maybe without even knowing it. And that could leave a nasty bruise on your practice’s bottom line—especially if you ever find yourself at …

  • Trick or Treat: A Creepy-Crawly Compliance Quiz Image

    articleOct 31, 2016 | 1 min. read

    Trick or Treat: A Creepy-Crawly Compliance Quiz

    Medicare compliance can be tricky—if not downright terrifying (sounds an awful lot like our favorite creepy-crawly holiday, Halloween). So when it comes to compliance, do you scare easily? Or, do you know the mean Medicare streets like the back of your hand? Take this frightening Medicare compliance quiz to find out whether your compliance basket is fraught with compliance tricks or filled to the brim with satisfying treats. Oh! And one last thing: while the scenarios and …

  • The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP Image

    articleOct 27, 2016 | 33 min. read

    The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP

    In October, we hosted a webinar dedicated to the most common Medicare misconceptions . We received a lot of questions from the audience—so many, in fact, that we’ve organized them all into one huge FAQ. Scroll through and check them out, or use the link bank below to skip to a particular section. The Therapy Cap ABNs Modifiers Supervision Prescriptions and Certifications Cash-Pay Rules and Regulations Re-Evaluations Everything Else   The Therapy Cap If a patient reaches …

  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • Common Questions from our G-Code Denials Webinar: Part 2 Image

    articleJul 30, 2014 | 4 min. read

    Common Questions from our G-Code Denials Webinar: Part 2

    I heard that some private insurance carriers are now requiring functional limitation reporting. Is this true? Some non-Medicare insurers do require functional limitation reporting (e.g., Texas Workers' Compensation). Check out this blog post to see a list of the ones we know about right now. Keep in mind, however, that this list is ever-changing—so if you’re unsure of whether a particular plan requires FLR, be sure to inquire directly with the carrier. If I did not submit …

  • CPT Update: Why the Valuation of the New PT and OT Eval Codes is Problematic Image

    articleJul 19, 2016 | 9 min. read

    CPT Update: Why the Valuation of the New PT and OT Eval Codes is Problematic

    The purpose of any type of reform is to drive change. And that’s certainly true when it comes to healthcare—and healthcare payment—reform. But, change often comes slowly—and in the wake of Medicare’s recently issued proposed physician fee schedule for 2017 , I have to wonder whether it’ll come too slowly for physical and occupational therapists. That’s because, while the Centers for Medicare & Medicaid Services (CMS) voiced its support for replacing the existing CPT codes for physical …

  • The Five Things You Need to Know Now About PQRS 2014 Image

    articleDec 4, 2013 | 10 min. read

    The Five Things You Need to Know Now About PQRS 2014

    Last Wednesday, just before we all headed home to gorge ourselves on turkey and pumpkin pie, Medicare released the Final Rule—all 1,369 pages of it. While it wasn’t exactly light reading, our fearless leader (and speed reader) Heidi Jannenga pored over this hefty document with a mission of finding all the Physician Quality Reporting System (PQRS) information that’s most important to you right now. Below is a breakdown of what you need to know about PQRS 2014. …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.