Changes to HCPCS Modifier 59

Date Issued: 11/12/2014

The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together either in all or in most situations.

One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

Modifier 59

Modifier 59, Distinct Procedural Service, is used to identify procedures/services, other than Evaluation and Management (E/M) services that are not usually reported together, but are appropriate under the circumstances.

CR8863, which discusses changes to HCPCS Modifier 59, provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU} modifiers) to define specific subsets of the - Modifier 59:
Effective for dates of service on and after January 1, 2015, CMS has established four new HCPCS modifiers to define subsets of Modifier -59, a modifier used to define a “Distinct Procedural Service.”

  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”

For example, a particular NCCI CPT code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other - X{EPSU} modifiers. The - X{EPSU} modifiers are more selective versions of the -59 modifier; so it would be incorrect to include both modifiers on the same line.

CMS and EmblemHealth will continue recognizing the - Modifier 59, but notes that CPT instructions state that Modifier 59 should not be used when a more descriptive modifier is available. While CMS and EmblemHealth will continue to recognize the - Modifier 59 in many instances, CMS and EmblemHealth may selectively require a more specific - X{EPSU} modifier for billing certain codes deemed to be at high risk for incorrect billing.