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

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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.

New Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Regular BannerNew Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Small Banner
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