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How to rightly use Modifier 59 and prepare your Medical Practice for Medical Billing Performance audits?

Modifier 59 unbundles services billed together on the same day. CMS defines Modifier 59 as:

“Modifier 59 identifies appropriate procedures not typically reported together.”

Coding pairs, or edits, can create mutually exclusive services. Coding pairs allow one service to be paid, with exceptions for separate performances. Without Modifier 59, unjustified coding pairs may not be reimbursed as distinct services. That’s where Modifier 59 and its subsets come to the rescue!

Modifier 59 is the most abused modifier, per OIG audits. We aim to review proper Modifier 59 use to improve claim accuracy impacted by bundling edits.

To begin with, how coders can verify when to use Modifier 59 with a coding pair:

At times, when unsure, coders can look up NCCI edit files presented by CMS. NCCI PTP edits define appropriate code combinations.

This is explained by NCCI Modifier Indicators of “0” and “1”:

NCCI indicators specify if Modifier 59 use is allowed (1) or not (0) for code pairs.

  • For NCCI edits with CCMI 0, never report the codes together. Reported together, Column One is paid, and Column Two is denied.
  • For NCCI edits with CCMI 1, report codes together only with specific modifiers.

Modifier 59 bypasses CCI edits under specific circumstances.

How can the use of Modifier 59 be justified to the payers?

Modifier 59 should only be used in genuine circumstances. To curb the misuse of Modifier 59, in 2015, CMS introduced the use of Subsets of Modifier 59 (X{EPSU}). Use subsets to specify Modifier 59 circumstances. CMS introduced new modifiers to override edits.

The four modifiers in the subsets are as follows:

  • XE: Separate Encounter: distinct service from a separate encounter. (This modifier is for separate encounters on the same date of service.) e.g., morning surgery followed by evening surgery due to aggravated circumstances. So, Modifier XE distinguishes the time of services for payment on the same day.
  • XS: Separate Structure: distinct service on a separate organ/structure. Encouraged use in pain management, podiatry, and dermatology codes. Treating multiple lesions on different sites without LT or RT modifiers. This modifier can also be used with different organs or regions.
  • XP: Separate Practitioner: distinct service by a different provider. Useful for services by two providers in the same or different specialties on the same day. Example: Patient has a stress test, then sees another provider for a rhythm ECG. Append XP to the ECG code to indicate a different provider than the stress test.
  • XU: Unusual Non-Overlapping Service: distinct service not overlapping the main service. Use XU for diagnostic procedures separately performed & not part of the primary intervention. Example: Diagnostic cardiac cath followed by medically necessary interventional cardiac procedure.

How to use Modifier 59 and its subsets properly?

  • Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
  • Append only when the services are clearly distinct from each other. Never use Modifier 59 together with its subset counterpart Modifiers.
  • Only use modifiers to bypass NCCI edits when criteria are met. Medical documentation must satisfy the required criteria.
  • These modifiers provide more specific reporting than Modifier 59 in certain situations. Use these modifiers instead of modifier 59 whenever possible.
  • Use evident medical judgment when and where the Modifier should be appended. Medical necessity plays a prominent role here.
  • Use CMS PTP NCCI edit documentation to make sure you are using it with the correct code in the coding pair.

Document Everything:

OIG reports highlight a lack of documentation in Modifier 59 abuse/fraud cases. Cases linked to insufficient documentation where services were not clearly distinguished.

Bottom Line:

Modifier 59 abuse cases caution organizations about improper use. Frequent modifier 59 use risks OIG or external audits.

Appending Modifier 59 recklessly can lead to audit risks. Use Modifier 59 subsets when possible to better explain its use.

Ensure documentation of medical necessity for each procedure and alignment of modifier use with guidelines.

Proper Modifier 59 use requires internal audits and documentation. Proper Modifier 59 use ensures fair payment and defends against audits.

AltuMED is a Healthcare Revenue Cycle Management technology and solutions company. Our technologically advanced Practice Management Software, PracticeFit optimizes the Medical Billing workflows for Medical Practices, Labs and Third-Party Medical Billing Companies helping them collect maximum revenue. Find out more.

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