Claim system edits search for duplicate and repeat services within paid, finalized, pending and same claim details in history. Therefore, unless applicable modifiers are included on your claim, the edits may detect same, or similar, duplicate services. Please share this information with your billing companies, vendors and clearing houses.
To prevent duplicate claim denials and ensure you are billing correctly, review your billing software and procedures. Some services on a claim may appear to be duplicates when, in fact, they are not. Use modifiers, as applicable, to identify procedures and services that are not duplicates. A complete list of modifiers can be found in the Current Procedural Terminology (CPT®) codebook. The following are a few examples of modifiers that may be used to indicate repeat, or distinct, procedures and services:
• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service.
• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.
• Modifier 59 may be used to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day.
• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59.
Note: Procedures and services submitted on your claim should always be supported by documentation in the patient’s medical record.
The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.
Changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.
The -59 modifier is the most widely used HCPCS modifier. Modifier-59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
• Different encounters;
• Different anatomic sites; and
• Distinct services.
The -59 modifier is
• Infrequently (and usually correctly) used to identify a separate encounter;
• Less commonly (and less correctly) used to define a separate anatomic site; and
• More commonly (and frequently incorrectly) used to define a distinct service.
The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CMS is establishing the following four new HCPCS modifiers (referred to collectively as
-X{EPSU} modifiers) to define specific subsets of the -59 modifier:
• 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, and
• 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 will continue to recognize the -59 modifier , but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP 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.
The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.
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