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

Modifiers 59 is the ‘go-to’ modifier that is used to ‘unbundle’ or appropriately distinct certain medical services that are billed together on same day. CMS defines Modifier 59 as:

“Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.”

There are a number of medical services that can form a ‘Coding-pair’ or a ‘Coding-edit’ that the payer might consider mutually exclusive. Which means only one of the services in the pair if supposed to get paid, while the other one might not, but there are indeed medically appropriate circumstances where the services were needed to be performed separately. In those times, without Modifier 59, if these coding pairs are not justified as distinct to one another, the packaged service won’t get reimbursed. That’s where Modifier 59 and its subsets come to the rescue!

However, according to various OIG audit and review reports, Modifier 59 is found out to be most frequently abused Modifier there is. Taking this opportunity, we would like to explain in detail the appropriate and inappropriate use of Modifier 59 and how much we can improve the clarity and quality of billed claims that form these 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 to NCCI edits files presented by CMS. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when you should or should not use certain HCPCS or CPT codes together in specified situations.

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

For understanding when or when not to use the Modifier, we need to look for the indicators mentioned against a pair of codes in the NCCI edits file, for simplification “0” means NO and “1” means YES to the use of a Modifier.

  • For NCCI PTP-associated edits that have a Correct Coding Modifier Indicator (CCMI) of “0,” never report the codes together by the same provider for the same beneficiary on the same date of service. If you do report the codes together on the same date of service, the Column One code is eligible for payment and Medicare denies the Column Two code.
  • For NCCI PTP-associated edits that have a CCMI of “1,” you may report the codes together only in defined circumstances by using specific NCCI PTP-associated modifiers

Modifier 59 is one of the several modifiers, that are used to ‘by-pass’ these coding pair edits that are enlisted in CCI edits document presented by CMS.

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 these subsets instead, to let the payer in which circumstances Modifier 59 was intended. CMS introduced four new Modifiers that could help better explain the scenarios in order to over-ride the edits:

The four modifiers in the subsets are as follows:

  • XE: Separate Encounter, a service that is distinct because it occurred during a separate encounter. (This modifier should only be used to describe separate encounters on the same date of service.) e.g., The first surgical session was performed in the morning, within aggravated circumstances another surgery needed to be performed in the evening. So, Modifier XE can be used to distinct ‘time’ of the operational services, which otherwise won’t get paid on the same day.
  • XS: Separate Structure, a service that is distinct because it was performed on a separate organ/structure. e.g., This modifier needs to be more commonly used, especially within pain management, podiatry and other dermatology codes. Where the provider treats multiple lesions on different sites or structures but other anatomical Modifiers such as LT (left) or RT (Right) are not applicable. This modifier can also be used with different organs or regions.
  • XP: Separate Practitioner, a service that is distinct because it was performed by a different practitioner. e.g., This one is pretty self-explanatory, this can be used to services provided by two providers in a group of same or different specialties on the same day. For instance; a patient has a cardiovascular stress test and is then referred to a different provider to do a rhythm ECG. Modifier XP must be appended to the rhythm ECG CPT code to indicate it was performed by a different provider than the cardiovascular stress test.
  • XU: Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service. e.g., Modifier XU can be used with diagnostic procedures when they are performed separately and they are not a component to the primary interventional procedure. For instance, based on the findings of a diagnostic cardiac catheterization, it is followed by a 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 the Modifier 59 together with its subset counterpart Modifiers.
  • Don’t use modifiers 59, -X{EPSU} and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. Medical documentation must satisfy the required criteria.
  • These modifiers give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible.
  • Use evident medical judgement when and where should 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:

According to OIG reports on abuse/fraud settlements related to Modifier 59 use, they have made clear that there was a serious lack of documentation on the Practitioner’s part. Also, they have linked the cases to lack of evidence in the documentation where the services were not made distinct to each other, enough or at all.

Bottom Line:

Modifier 59 abuse settlement cases are found abundant online as a word of caution for many organizations getting under investigation quietly easily for its improper use. Frequent and unnecessary use of this modifier comes with perils of OIG or external audits.

Many billers are tempted to append Modifier 59 to a service to override an edit, but this can set up their medical practice for a substantial audit risk if it is applied recklessly. If Modifier 59 has to be appended, prefer opting for its subsets instead to better explain its actual reason for use.

In the end, a practice should make sure they document the medical necessity of performing each procedure, and include details beforehand showing how the use of the modifier is indicated by the guidelines.

Most proper use of Modifier 59 is through frequent internally scheduled audits (to catch the abuse in-advance) and documentation of appropriate use in medical notes. These might be the provider’s best defense against in case of an external audit which also may boost the chances of payment of a service fairly, when used correctly.

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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