Monday, November 24, 2014

Modifier 59 Use – Outpatient Therapy Services

Dan Ciolek

Recently there has been some confusion among providers of Part B therapy services regarding how to properly comply with the National Correct Coding Initiative (NCCI) edits. On August 15, CMS released Change Request 8863 and the related MLN Matters article MM8863 – Specific Modifiers for Distinct Procedural Services. These documents discuss changes to HCPCS modifier -59, which become effective January 1, 2015. Modifier -59 is used to define a “Distinct Procedural Service” and 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. CR8863 provides that 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.

In response to provider questions regarding whether these new modifier codes should be used for outpatient therapy services, CMS provided the following guidance to AHCA and other organizations to share with providers: 

Re: CR 8863 & MM 8863 – Specific Modifiers for Distinct Procedural Services

 · CMS is establishing four new HCPCS modifiers to define subsets of the 59 modifier, a modifier used to define “Distinct Procedural Services”

· The four new modifiers:

o XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

o XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

o XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

o XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service 

At this time, the below statements represent CMS policy about the use of the new X{EPSU} modifiers for therapy services; and, is being sent in response to inquiries about their use on claims for therapy services.  

The following information regards the new X{EPSU} modifiers and their use with therapy procedures and the National Correct Coding Initiative (NCCI) edits: 

· You can keep using the 59 modifier until CMS issues specific instructions about the use of the new X{EPSU} modifiers.  

· Because the X{EPSU} modifiers were developed to be used in the place of the 59 modifier, the XP modifier (used to indicate a different “practitioner”) is not appropriate to use [at this time] to distinguish between therapy disciplines as CMS uses the therapy modifiers — GN, GO, or GP — to track and differentiate between the 3 therapy disciplines.  

· For purposes of applying the NCCI edits for outpatient therapy services, you can continue to use the 59 modifier, rather than the X{EPSU} modifiers, to denote distinct therapy procedures until such time CMS issues future clarifying instructions.  

If you have questions please contact Dan Ciolek at dciolek@ahca.org.  

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