This may impact your reimbursement in the coming New Year 2015! Make sure you and your staff knows about these new changes.
Let's welcome the new year 2015 with more easy to use Modifier 59 and say hello to its the new 4 X's HCPCS modifers added by CMS.





2015 Medicare Modifier 59 Changes

If you are familiar with the CCI Edits or the Correct Coding Initiative Edits? isn't it that Modifier 59 has always been the modifier that comes to our mind to bypass edits with column 2 "1"?

We use modifier 59 for the purpose of telling the payers that the procedure(s) was performed as "DISTINCT PROCEDURAL SERVICE"
A little background - why are we using Modifier -59.
The Procedural Service can be "Distinct" due to the fact that it was a same-day procedure performed on:

• a different body site or organ system.
• a different or separate lesion.
• a different area of injury
• a different procedure
• a separate incision or excision
• a different day of encounter
• a different practitioner
• a different session
• a distinct and independent procedure/surgery/encounter from other services performed.

The CPT Manual clearly defines Modifier -59 as follows:
"Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. 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. Documentation must support a different session, different procedure or surgery, different site or organ system. separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than Modifier 59. Only if no more descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used. NOTE: 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

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. If you are audited for misuse of Modifier 59, your documentation will be checked so it must clearly state that the criteria was met
CMS introduced the 4 New Modifiers for 2015 (not to replace Modifier 59 - just not yet!).

These 4 new modifiers were developed for more specificity when the procedure is truly a DISTINCT procedure! These are Specific Modifiers for Distinct Procedural Services or subsets of Modifier -59.

2015 Medicare Modifier 59 Changes and the 4 New Modifiers
1. XE "Separate encounter, a service that is distinct because it occurred during a separate encounter".
2. XS "Separate structure, a service that is distinct because it was performed on a separate organ/structure".
3. XP "Separate practitioner, a service that is distinct because it was performed by a different practitioner".
4. 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 Modifier -59 but you have to make sure you will only utilize this modifier when there is no other specific modifier that may describe your "distinct" procedure service.
When using this modifier, Medical Documentation is vital and essential to support medical necessity. This must be well-documented on the patient's medical record.
References:

• 2015 CMS Modifier 15 Changes Transmittal 1422 CR 8863
• modifier59-per NCCI (Modifier -59 Per NCCI Edits and the 4  subsets New Modifiers X(ESPU)
• CPT Code Books

​Guideline:
The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days



​

WHEN IT IS APPROPRIATE:

• Treatment of problem requiring a return to operating/procedure room
• More extensive than original procedure
• Unanticipated clinical condition
• Therapy following a diagnostic, surgical procedure                                
• Each case requires surgical documentation and evaluation

Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in same specialty, same group are to bill and are reimbursed as a single physician

Key to Remember!  Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

It is NOT APPROPRIATE WHEN:

• Not appropriate for E/M - Evaluation and Management! or assistant surgery services

References:
CMS Medicare Website
Coding Books
​Payers Websites