CODING Q&A

Modifier 59 — You’re Probably Using It a Lot, But Are You Using It Correctly?

SUZANNE L. CORCORAN, COE

Modifier 59 is commonly called the “unbundling” modifier. It is one of the most commonly used modifiers, but it is also the most misused. And now there are new “X” modifiers to learn.

Q. How does CPT define modifier 59?

A. CPT defines modifier 59 as a “Distinct Procedural Service.” CPT explains: “Modifier 59 is used to identify procedures or 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 or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However when another established modifier is appropriate, it should be used rather than modifier 59.”

Q. When is modifier 59 used?

A. According to CMS, modifier 59 is the most widely used modifier. Use modifier 59 when a procedure or service includes two or more CPT codes that are bundled under Medicare’s National Correct Coding Initiative (NCCI) edits, yet circumstances support separate charges. It is not commonly supported in eye care.

Q. But modifier 59 is appropriate when procedures are preplanned and have distinct indications, correct?

A. No. CMS published a clarification stating, “Use of modifier 59…does not require a different diagnosis for each HCPCS/CPT code procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.”

Q. Are different areas of the retina (eg, macula and peripheral retina) considered different anatomic sites?

A. No. The CMS clarification is specific and states, “The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ…Treatment of posterior segment structures in the eye constitute a single anatomic site.”

Q. What are the new “X” modifiers?

A. CMS established four new HCPCS modifiers, effective Jan. 1, 2015. They are:

• XE - Separate Encounter

• XS - Separate Structure

• XP - Separate Practitioner

• XU - Unusual Non-Overlapping Service

On Medicare claims, these four modifiers should be used instead of modifier 59. Other payers are not obliged to follow Medicare guidelines although many do.

The new modifiers are a more selective version of modifier 59. Their use will allow tracking of the various reasons this modifier is used or abused. CMS noted “… that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.” The use of modifiers 59 or X{EPSU} on a claim indicates that documentation is available in the patient’s record that will support the distinct or independent identifiable nature of the service.

Q. When are these modifiers used?

A. You should only use modifier XE to describe separate encounters on the same date of service. For example, you do an exam and extended ophthalmoscopy on a patient with a retinal detachment in your office in the morning. You do the RD repair (67108) at the hospital later the same day. NCCI edits bundle 92225 with 67108. Your claim will append modifier XE (or 59) to the claim for 92225 because it was performed in the office — a separate encounter.

Modifier XS describes a service that is distinct because it was performed on a separate organ or structure. An example might be a vitrectomy/endolaser (67040) on the right eye and a laser PRP (67228) on the left eye. Your claim will append modifier XS (or 59) to 67040, since it is normally bundled with 67228. Another example of XS use would be a patient with retinal pathology in both eyes, necessitating extended ophthalmoscopy (92226) bilaterally. In the same session, you deliver an intravitreal injection (67028) in the right eye. Modifier XS is appended to the extended ophthalmoscopy in the untreated eye (92226-LT).

Modifier XP describes a service that is distinct because it was performed by a different practitioner. For example, your pediatric ophthalmologist examines a premature infant in the NICU and performs extended ophthalmoscopy (92225); she finds ROP. Later the same day, her partner, a retina specialist, performs ROP laser (67229) on the same eye. Modifier XP is appended to 92225 to indicate that the two procedures are distinct because different physicians performed them (even though they are from the same practice). Note: Depending on the payer, you may also need to append modifier XP to the exam since it is also usually bundled with a laser.

Modifier XU is the most difficult and is likely to be extremely rare in ophthalmology. CMS says it is used to describe a service that is distinct because it does not overlap usual components of the main service, such as when a diagnostic procedure is performed and then a decision is made to perform a therapeutic/surgical procedure.

Q. May modifier 59 or the X modifiers be used together with other modifiers?

A. Not usually. The CPT definition states, “…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.” An exception is made for the use of informational modifiers (eg, RT, LT, E#). 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. RP

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