Cloud with snow Learn how your practice can weather the flurry of healthcare changes throughout 2017 in our February webinar. Register now.


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.

9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Regular Banner9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Small Banner
  • 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 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 • …

  • articleDec 9, 2010 | 2 min. read

    The Medicare and Medicaid Extenders Act of 2010

    This legislation would prevent the scheduled 25.5% Medicare payment cut to physical therapists and other health care providers paid under the physician fee schedule. Today, the US House of Representatives passed Senate Amendment to H.R. 4994 , the Medicare and Medicaid Extenders Act of 2010 (by a vote of 409-2). This legislation would prevent the scheduled 25.5% Medicare payment cut to physical therapists and other health care providers paid under the physician fee schedule. The provision in …

  • Have You Considered These 3 ICD-10 To-Dos? Image

    articleFeb 3, 2015 | 5 min. read

    Have You Considered These 3 ICD-10 To-Dos?

    “How do you eat an elephant? One bite at a time.” That’s how the age-old adage goes, but aside from it being a totally messed-up saying—why are we eating elephants?—it also falls totally flat in my book. When we talk about eating an elephant, it implies that we’re devouring something. In reality, though, with any significant or substantial endeavor, we’re actually trying to triumph. And I’m not sure if anyone would count gorging on a pachyderm as …

  • articleNov 29, 2011 | 3 min. read

    PQRS: The Case for Registry over Claims Based Reporting

    Here at WebPT HQ, we are gearing up for PQRS 2012. One of the pieces of PQRS that is most commonly misunderstood is the difference between claims and registry based services. Let's take a minute and clear this up. Claims and registry-based reporting both result in the same outcome for your clinic-- successful participation in PQRS. WebPT offers both options with claims-based being priced $99 per calendar year and registry-based at $299 for the calendar year. Many …

  • Think You Know PQRS? [Quiz] Image

    articleDec 2, 2015 | 1 min. read

    Think You Know PQRS? [Quiz]

    PQRS 2016 is on the horizon, and whether you’re an old pro or a reporting rookie, the details of this Medicare quality data program can be tough to keep straight. And with a potential 2% negative payment adjustment on the line, it’s imperative that you understand every facet of this quality data reporting program from A to Z—er, P to S. Think you’ve got PQRS down pat? Prove your smarts with our ten-question quiz. Need a bit …

  • New and Improved: Details on Sustainable Growth Rate Formula Replacement Image

    articleJun 1, 2015 | 3 min. read

    New and Improved: Details on Sustainable Growth Rate Formula Replacement

    Ding-dong—the Sustainable Growth Rate (SGR) formula is dead . As of April 16, 2015—after 17 temporary patches—the wizards in Washington have permanently repealed the flawed SGR formula that threatened to significantly cut Medicare payments. Now, when payments exceed the growth in per-capita gross domestic product, PTs will no longer face reduced payments. Instead, they can look forward to a bit more stability, simplicity, and cash flow for the next decade. The new payment determination process begins with …

  • The PT’s Guide to Surviving a Medicare Audit Image

    articleMay 30, 2016 | 5 min. read

    The PT’s Guide to Surviving a Medicare Audit

    “How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes …

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