New “Distinct Procedural Service” (-59) Modifiers on the Way–Anesthesia and Pain Management Practices Take Note
Many medical services and procedures can be performed either on their own or in conjunction with another service or procedure. The National Correct Coding Initiative (CCI) identifies pairs of services that a physician cannot normally report for the same patient on the same date of service. The two services may be mutually exclusive, as when one is performed only on female patients and the other only on males. Most commonly, the reason for the linkage—the CCI “edit” that bundles the two services and prevents separate payment—is that the second service in the pair is a component of the more extensive service performed by the same physician for the same patient at the same encounter. An example familiar to anesthesiologists is the bundling of postoperative pain management procedures with an anesthetic delivered through the same catheter.
Under appropriate circumstances, the physician may bill for two services in a code pair and include a CPT®/HCPCS modifier that will bypass the edit and allow both services to be paid. The most common of the 35 modifiers that deactivate a CCI edit is modifier 59, which serves to indicate that a physician performed a distinct procedure or service for a patient on the same day as another procedure or service. The CPT Manual defines modifier 59 as follows:
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Thus, following the postoperative pain medicine example above, an anesthesiologist might report general anesthesia for a total knee arthroplasty with CPT code 01402 and, on the same claim, the separate placement of an epidural catheter for postoperative analgesia using code 62319-59.
Modifier 59 has long been a burr in Medicare’s fraud and abuse saddle. Almost ten years ago the OIG published a study (Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits) showing that forty percent of code pairs billed with modifier 59 in 2003 did not meet program requirements, resulting in $59 million in improper payments. Last month, in Transmittal 1422 and its accompanying MedLearn Matters article (MLN Matters® MM8863, CMS noted “Because [modifier 59] can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative. . . 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 is concerned by this pattern of abuse because such behavior siphons off funds that should be available to legitimate and compliant providers and additionally unnecessarily increases beneficiary costs” and announced that it will establish four new HCPCS modifiers to define specific subsets of the -59 modifier. The new modifiers, referred to collectively as the -X{EPSU} modifiers, are listed in the table below.
X{EPSU} MODIFIERS
- XE Separate Encounter a service that is distinct because it occurred during a separate encounter
- XS Separate Structure a service that is distinct because it was performed on a separate organ/structure
- XP Separate Practitioner a service that is distinct because it was performed by a different practitioner
- XU Unusual Non-Overlapping Service the use of a service that is distinct because it does not overlap usual components of the main service
These new modifiers will be effective as of January 1, 2015. CMS will continue to recognize modifier 59 “as a default,” for the time being, but the Agency reminds physicians and coders that modifier -59 should not be used when a more descriptive modifier is available and encourages “the rapid migration of providers to the more selective modifiers.” CMS also advises that the Medicare Administrative Contractors (MACs) “are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.”
What do these confusing pronouncements mean as a practical matter, and which modifier should one in fact use to code a distinct procedural service after January 1, 2015? We would suggest deferring changes to your systems until you receive further instructions from your MACs and from your non-Medicare (commercial) carriers. Anesthesia practices will also want to check the CCI in January, when CMS typically releases corresponding CCI guidance specific to each range of HCPCS codes. The next version of the CCI manual may well implement CMS’ option, as stated in the Transmittal, to “selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.” Until there is more information, modifier 59 should remain the default.
And, as always, we encourage you to watch for further information in a future Alert.