Modifier -59, the New/Not So New, Hot Topic – New Subset of Distinct Procedural Service Modifiers Introduced

Christina Panos's picture

By Christina Panos, RHIA, CTR

Modifier -59 usage has long been the topic of many articles, educational programs, bulletins, as well as audits.  At this time of year where we see not only the leaves and temperature changing, we see modifications to major payment systems such as finalization of the Hospital Inpatient Prospective Payment System updates, proposed & upcoming final changes to the Hospital Outpatient Prospective Payment System (OPPS), the Physician Fee Schedule, and more.  Similarly on August 15, 2014, CMS released Change Request 8863, bringing with it modifications to the list of reportable modifiers, more specifically the addition of further distinct procedural service modifiers.

CR 8863 introduced the following four modifiers, otherwise known as the –X {EPSU} modifiers, as a subset of Distinct Procedural Service modifier -59:

  • 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

While CMS will continue to recognize modifier-59, accepting either a -59 or the more selective –X {EPSU} modifiers, contractors may choose to require reporting of these more specific modifiers.  That said, CMS does encourage rapid adoption of the new modifiers and further reminds the provider community of the definition of modifier 59; specifically that modifier -59 should only be used if there is no other more descriptive modifier available.

While the effective date of the new –X {EPSU} modifiers is a few months away, January 1, 2015, it is not too soon to start thinking about the impact to your organization and outlining the necessary implementation steps. Consider the following.

A review of the new modifiers should be incorporated into any upcoming annual education plans that are likely to also include a review of upcoming coding and OPPS changes.  In most organizations, modifier assignment extends beyond HIM’s outpatient coding process.  Some have processes in place to assign modifiers up front, at the point of charge entry, when appropriate; as well as back end processes, as a result of billing edits, to investigate these edits and assign modifiers as appropriate prior to billing.  Therefore, broad based education will be required at all points of modifier assignment and should include various professionals involved in the Revenue Cycle processes, such as:

  • Coders
  • Charge Entry Staff
  • Clinical Department Staff
  • Billing/ Patient Accounting Staff
  • Charge Master Staff

As noted, modifier -59 usage may not be limited to just HIM coders; therefore, education should reach to all of these impacted professionals. 

Beyond education the mechanics and systems utilized within each organization to assign modifiers should be considered.  System or system related updates may be required to accommodate these additional new modifiers.  Take a look at some of the following to identify any potential impact and outline update plans accordingly:

  • Charge Master
  • Charge Entry Screens
  • Order Entry Screens
  • Charge Capture Tools
  • Downstream Clinical Systems
  • Billing Systems.

Additionally, keep an eye out for additional communication from your Medicare Administrative Contractor (MAC) and/or CMS, further defining required modifier usage.  As noted in the change request, contractors or CMS may selectively require the use of the X- {EPSU} modifiers in the future to address high risk billing patterns.  While minimal information has been published to date on these modifiers, I would expect more to come in the future.