CMS Establishes 4 Modifiers to Define Subsets of Modifier 59

August 18, 2014
Rick Gawenda

The Centers for Medicare and Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Because it can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)”, it is the most widely used modifier. It is also associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals and even civil fraud and abuse cases.

CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows:

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    1. Modifier 76 is a repeat procedure by the same provider. That is not the same as the XE modifier by definition since it states a service that is distinct because it occurred during a separate encounter. Will have to wait for examples from CMS.

  1. Should ‘separate encounter’ be construed to mean ‘separate and non overlapping block of time’ … or would that be -XU? If one performs/bills 15 min manual, 15 min ther ex, and 15 min ther activity (let’s assume one of those combos triggers an edit – am not looking at the CCI list at the moment)… would one bill -59 and -XE?? or -59 and -XU b/c they are inherently non-overlapping?

  2. have we ever gotten further clarification on these? Our corporate revenue integrity people contacted us recently and told us not to use the 59 modifier and they would put the correct x modifier on it…..I’m looking into it, but they would not know what modifier to use as it should be the PT. Have you heard anything new?

    1. CMS has not mandated the use of the 4 new subsets of modifier 59. You can still use modifier 59.