Private Payors Adopting Changes to Modifier 59

modifier59Many private payors have announced they will use the new 59 (Distinct Procedural Service) modifier subsets released by CMS this past summer. The four modifiers, collectively know as the  X(EPSU) modifiers, will be effective for most carriers on January 1, 2015.

The following payors have announced use of the new modifier subsets. It is likely that many other carriers will also begin using the new modifier subsets.

  • UnitedHealthcare
  • Anthem BCBS in Connecticut, Ohio, Indiana and New Hampshire
  • Massachusetts – BCBS, Fallon Health, Mass Health, Tufts Health Plan
  • New York – Empire BCBS

The subset modifiers were issued by CMS due to concern over the chronic overuse of modifier -59  resulting in many overpayments following inappropriate use. The new modifiers provide more specificity of the distinct procedural service as follows:

  • 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

CMS and the private carriers will continue to recognize the -59 modifier for now but it is important to note that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. Carriers may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing. As an example, a particular national correct coding initiative (NCCI) procedure to procedure code pair edit may be identified as payable only with the XE separate encounter modifier but not the 59 or other X(EPSU) modifiers.

UnitedHealthcare has published which modifiers will be considered in administering their reimbursement policies as well as the date of the policy implementation.

  • Anesthesia – XE,XU – 2/15/2015
  • Bilateral – XS – 1/1/2015
  • CCI Editing – XE, XP, XS, XU – 2/15/2015
  • Maximum frequency per day – XE,XS,XU – 1/1/2015
  • Obstetrical – XE,XS,XU – 2/15/2015
  • Pediatric/Neonatal Critical Care – XE,XS,XU -3/1/2015
  • Procedure to Modifier – XE, XP, XS, XU – 2/15/2015
  • Professional/Technical Component – XE, XP, XS, XU – 2/15/2015
  • Radiology Multiple Imaging Reduction – XE, 1/1/2015
  • Rebundling –  XE, XP, XS, XU – 2/15/2015

It is important to understand the four new modifiers and them to describe your services as appropriate.

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