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Rapid Migration to Specific Modifiers over 59 for NCCI Edits

Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, September 16, 2014 Posted in: Outpatient Rehab

59 Modifier Not Good Enough in 2015

A MedLearn Matter (MM8863) was released mid-August preparing outpatient facilities to learn, educate and begin differentiating the REASON that paired CPT® codes should be payable when they are on the edit list.

CMS released this new change request to keep people from ‘unbundling’ services generally paid as a pair. CMS has published a list of those codes they feel are CPT® codes that have ‘subset’ associated care. Each procedure has a value associated to it based on distinct resources (RVU’s) needed to complete the various codes. CMS says that when a code has a component code, it would be ‘double dipping’ on the payment formula to allow full payment for both. To bypass an edit at the MAC level, a reason was needed for why you should be paid above and beyond what is considered the base or primary CPT® code.

CMS then adopted the Medicare National Correct Coding Initiative (NCCI). These are edits used in part B billing for physicians and outpatient procedural facilities such as therapy practices.

Because CMS gave an ‘out’ to bypass the edits by appending ‘59’ code meaning distinct and separate they believe that with the volume of use, the 59 modifier signals inappropriate unbundling.

Given that, CMS’ new instruction will mandate that if you need to bypass and NCCI edit so that you receive payment for codes performed the same day individually, they want to know the EXACT reason. That said, CMS released and defined NEW CODES that will be utilized beginning with the outpatient fiscal year or Jan. 1, 2015.

CMS cited that the 59 modifier (HCPCS) is used too broadly and they want the person billing for the procedure to be MORE exact. More exact means they have added four new codes that will be used INSTEAD of the 59 modifier. These codes all begin with letter ‘X’ and the next letter designates the REASON. E is for separate Encounter and would appear as XE modifier. S as the second letter is considered for a separate Structure or organ; that code will be XS. P is utilized when the Practitioner performing the service was different; XP. The letter U will be used for ‘UNUSUAL’ non-overlapping service and would not be a component of the main service. The code applied to the bill would appear as XU. Even though CMS is not sunsetting the 59 code, they caution that it should be used very selectively and truly when one of the other four more distinct codes is not appropriate.

In their guestimate, this should abruptly change the use of modifier 59, and I would have to agree.  The 59 modifier will NOT go away, it can still be utilized per CMS.
This coding is especially important in clinics that have more than ONE discipline available. CMS already has the ability to tweak out distinct and separate practitioner because therapists utilize GP, GO and GN for their various plans of care and associated billing to that plan; why they choose not to use this rather than the new XP is unknown.

Be aware, start to prepare and train staff to walk away from 59 when a more descriptive code is appropriate.  Utilize the newest modifiers to designate ‘distinct and separate’ for the cause indicated by the new code. Given these new rules, you validate that separate payment should occur.