The Center for Medicare & Medicaid Services (CMS) recently announced that it is introducing four new HCPCS modifiers to further scrutinize the use of modifier -59. The implementation date for these modifiers is Jan. 1, 2015, however, local Medicare contractors may implement earlier.

The announcement of these new HCPCS modifiers ties closely with an earlier publication from CMS regarding modifier -59. In June 2014, CMS published an article to provide guidance on the use of modifier -59 almost as a prelude to these HCPCS modifiers. The June article revised , which provides detailed instructions and guidance on the proper use of modifier -59. Careful review of MLN Matters® SE1418 shows a similar relation to the August , the publication introducing these new HCPCS modifiers.

In the MLN Matters® MM8863 article, CMS speaks to the proper use of modifier -59. Specifically, CMS states that modifier -59 "is the most widely used HCPCS modifier and 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."1

CMS goes on to indicate that "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."2

The four new HCPCS modifiers, referred to collectively as the -X { EPSU} modifiers, are:

  • -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

Of these new modifiers, modifiers XE and XS will likely be most applicable in pathology and laboratory billing. Based on the modifier descriptors, it is less likely that modifiers XP and XU in the pathology and laboratory industry. 

Because of the detailed descriptions associated with these modifiers, it should be more evident as to why the provider is overriding the NCCI edit, and these modifiers will allow CMS to identify whether the edit was overridden appropriately. When these modifiers are implemented by the Medicare Contractors, CMS will be able to see more clearly the reason the providers are using them, which may result in specific edits being implemented by the various contractors.

Even though these new modifiers will be effective as of Jan. 1, 2015, CMS isn't abolishing modifier -59. According to CMS, modifier -59 will continue to be recognized, but CMS reminds providers that current procedural terminology (CPT®) instructions state that modifier -59 should not be used when a more descriptive modifier is available.

Early adoption of these modifiers by the Medicare contractors is a possibility. CMS states that contractors are not prohibited from requiring the use of selective modifiers in lieu of modifier -59 before CMS creates national edits around the modifiers. As a result, local contractors could implement the use of these modifiers and create edits prior to the Jan. 1, 2015 implementation date. Providers should be very vigilant in reviewing denials, bulletins, and other publications from their local contractors in order to stay abreast of when their contractor will implement the modifiers.

1 , CMS (Web 15 Aug. 2014).
2 Ibid.

This commentary is a summary prepared by web2pro's Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of Pathology. This commentary does not supplant the American Medical Association's current listing of CPT codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT codes. Please refer to your 2014 CPT Code Book, annual CPT Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association ("AMA"). The AMA is the owner of all copyright, trademark and other rights to CPT and its updates.

Author - Female

About the author

Kimberly West, CPC is National Pathology Auditing & Coding Manager of web2pro Business Performance Services.