Modifier 59: New, Revised Issues Relating to NCCI Edits in 2015

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AudioEducator is conducting an audio conference on the new, revised issues relating to the updating of the NCCI guidelines for 2015 as related to modifier - 59 with expert Margie Scalley Vaught.

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The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place ~ The CMS

According to the Centers for Medicare & Medicaid Services (CMS)*, modifier 59 has been abused consistently by the providers to bypass the National Correct Coding Initiative (NCCI). The CMS believes that modifier 59 often overrides the edits in the exact circumstance for which it has been created in the first place, and that a more precise coding options, proper education and editing is needed to reduce errors associated with this overpayment. The misuse of modifier 59 has resulted in high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases.

National Correct Coding Initiative

The NCCI was developed to endorse correct coding by providers and to prevent payments for improperly coded services. The CMS developed the coding policies based on coding conventions defined by the CPT manual, national policies and edits, coding guidelines, analysis of standard medical practices, and review of current coding practices.

Specifically, the CCI edits contain pairs of HCPCS codes that commonly should not be billed together by a provider for a beneficiary on the same date of service. However, in some situation a provider may bill for two services in a CCI code pair and include a modifier on the claim that would bypass the edit and allow both services to be paid. The modifier used is a two-digit code which further describes the service performed, and Modifier 59 is one of the 35 modifiers that are used to bypass the CCI edits.

The prime issue associated with modifier 59 is that it is used in a wide array of circumstances like different encounters, different anatomic sites, and distinct services. Additionally, modifier 59 is infrequently (and usually correctly) used to identify a separate encounter, less commonly (and less correctly) used to define a separate anatomic site; more commonly (and frequently incorrectly) used to define a distinct service.

Four New Modifiers to define Subsets of the commonly Used Modifier 59

To overcome the abuse of Modifier 59, the Centers for Medicare & Medicaid Services have announced a new series of modifiers which would provide more specificity of the distinct procedural service.

The four new modifiers, collectively called X{EPSU} modifiers, to define specific subsets of modifier 59 are 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

Challenges Providers Will Face Using the New Modifiers

The CMS is not eliminating the Modifier 59 completely even though the new modifiers are effective from Jan 2015, however, the agency wants to make it clear to the providers that modifier 59 should not be used when a more descriptive modifier is available. Additionally, CMS says that even before it might create national edits around these modifiers, contractors are not prohibited from requiring the use of selective modifiers in lieu of modifier -59. Therefore, local contractors may begin creating edits long before CMS does, and hence the providers need to be extra vigilant.

The short notice provided to physicians and a lack of clarity regarding the mandatory use of the new modifiers resulted in many uncertainties. To cope up with the challenges:

  •     Vendors need to make sure they have new modifiers loaded in their system
  •     Educate and learn about NCCI edits
  •     See the CMS guideline on How to Use the National Correct Coding Initiative (NCCI) Tools (PDF), and other CMS updates

Expert speaker Margie Scalley Vaught — who has over 30 years of experience in healthcare—will shed light on the 2015 new and revised issues in NCCI edits relating to modifier 59 in a informative audio session. She will discuss about the newly released X modifiers, and also help you understand when you can and cannot use Modifier 59 from a CMS and CPT standpoint.

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AudioEducator, the country’s leading source of business-enhancing information, has been providing knowledge and training to healthcare professionals for trending industry topics for more than a decade. With an esteemed panel of industry experts, it helps professionals get information directly from the veterans and get their queries answered directly. AudioEducator specializes in audio conferences, training webinars, transcripts, DVDs on a wide array of healthcare topics like medical coding, billing, HIPAA compliance, food safety, rehab, pharma & biotech, and more.

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