Question

to determine 1 whether modifier 59 is being used inappropriately to bypass medicare's national correct coding initiative (CCI) edits and 2 to what extent Medicare carries are reviewing the use of modifier 59. What should CMS encourage carriers to do moving forward with regards to the use of modifier 59?

Answer 1

Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.

To appropriately use modifier 59, physicians should not use it on an E/M service code. When billing for an E/M service and a procedure that is not typically included in an E/M visit, or is not typically done on the same day, physicians should use the 59 modifier on the non-E/M service code.

Modifier 59 is not going away and will continue to be a valid modifier, according to Medicare. However, modifier 59 should NOT be used when a more appropriate modifier, like a XE, XP, XS or XU modifier, is available. Certain codes that are prone to incorrect billing may also require one of the new modifiers.

CMS is encouraging providers to adopt the modifiers quickly; they may be used by Medicare and considered valid even before national edits are in place on January 1st.

New Modifiers

Modifier 59 is not only the most used modifier, but it’s also the most abused. And while the abuse may be unintentional at times, the improper coding leads to incorrectly paid claims. As audits have increased, CMS has realized that more specific modifiers may be helpful in deterring this abuse.

The -X{EPSU} modifiers are essentially a subset of modifier 59. CMS believes their usage will help reduce overpayment errors.