The March 2018 Payment Strategies column reviewed the use of modifier -59 and the new -X{EPSU} modifiers that were released on January 1, 2015. The column informed wound care stakeholders that the National Correct Coding Initiative (NCCI) Edit Manual provides instructions to append modifier -59 or the -X{EPSU} modifiers to the code in column 2 of the NCCI procedure-to-procedure (PTP) edits when it is appropriate to unbundle the column 2 code from the column 1 code. Less than a year later, on February 15, 2019, the Centers for Medicare & Medicaid Services released Change Request 11168.1,2 The Change Request simply states that effective July 1, 2019, the Multi-Carrier System (MCS) Claims Processing System will recognize modifier -59 and the -X{EPSU} modifiers when they are appended to either the column 1 code or the column 2 code of the NCCI PTP edits.
To understand the impact of Change Request 11168, let us review some key points about the NCCI PTP edits, modifier -59, and the -X{EPSU} modifiers.
NCCI PTP Edits Key Points
* Two NCCI edit tables are released each quarter: one for physicians and other qualified healthcare professionals and one for hospital outpatient provider-based departments.
* NCCI PTP edits define when two codes should not be reported together, either in all situations or most situations. The edits apply to claims from the same provider, for the same Medicare beneficiary, and on the same date of service.
* The NCCI PTP edits consist of the column 1 and column 2 codes.
* Each NCCI PTP edit is assigned a Correct Coding Modifier Indicator (CCMI):
[white circle] CCMI "0" indicates that NCCI-associated modifiers cannot be used to bypass the NCCI PTP edit. NOTE: If the two codes are reported together, the code in column 1 of the NCCI PTP edits will be eligible for payment; the code in column 2 will be denied.
[white circle] CCMI "1" indicates that NCCI-associated modifiers may be used to bypass an NCCI PTP edit under appropriate circumstances.
[white circle] CCMI "9" indicates that the NCCI PTP edit has been deleted and is displayed only for historical purposes.
* NCCI-associated modifiers should be used only when the two codes in the NCCI PTP edit relate to
[white circle] separate patient encounters
[white circle] separate specimens
[white circle] separate anatomic sites
NOTE: If the two procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be used.
Modifier -59 Key Points
The definition of modifier -59 is "distinct procedural service." Modifier -59 can be used when documentation supports a different session, different procedure or surgery, different site or organ system, separate incision/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. Wound care stakeholders often misuse modifier -59 because they misinterpret the "different procedure or surgery" portion of the modifier -59 description. Even though the two codes in an NCCI PTP edit usually represent "different procedures or surgeries," the NCCI PTP edit indicates that the two "procedures/surgeries" cannot be reported together if performed at the same anatomic site and at the same patient encounter.
* The NCCI definition of different anatomic sites includes different organs, different anatomic regions, or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site.
* Use of modifier -59 does not require a different diagnosis for each reported code. In fact, 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 during separate patient encounters.
* Modifier -59 has been the most used and abused modifier to bypass NCCI PTP edits with a CCMI of "1."
* Modifier -59 should not be used if a more descriptive modifier is available; the -X{EPSU} modifiers may be more descriptive in some cases.
* Modifier -59 should not be used on evaluation and management codes.
-X{EPSU} Modifier Key Points
* Here are the definitions of the -X{EPSU} modifiers:
[white circle] XE: "Separate encounter, a service that is distinct because it occurred during a separate encounter." This modifier shall be used only to describe separate encounters on the same date of service.
[white circle] XP: "Separate practitioner, a service that is distinct because it was performed by a different practitioner"
[white circle] XS: "Separate structure, a service that is distinct because it was performed on a separate organ/structure"
[white circle] XU: "Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
* Modifiers XE, XP, XS, and XU were developed to provide greater reporting specificity in situations where modifier -59 was previously reported and should be used instead of modifier -59 whenever possible.
* Use the -X{EPSU} modifiers only for NCCI PTP edits with a CCMI of "1" and when it is appropriate to unbundle the column 1 and column 2 codes.
The Table describes the appropriate use of NCCI-associated modifiers prior to and after July 15, 2019.
SUMMARY
* Modifiers may be appended to codes in NCCI PTP edits only if the clinical circumstances justify the use of the modifier.
* Modifier -59 and the -X{EPSU} modifiers shall not be used to bypass an NCCI PTP edit unless the proper criteria for use of the modifier are met.
* The MCS Claims Processing System is programmed to use NCCI-associated modifiers to allow payment of both codes of an NCCI PTP edit with a CCMI of "1."
* Effective July 1, 2019, the MCS Claims Processing System must begin recognizing modifier -59 and the -X{EPSU} modifiers on either the column 1 code or the column 2 code of an NCCI PTP edit.
* Wound care stakeholders should prepare for this new process but should not implement it until dates of service on or after July 1, 2019.
NOTE: Inform your coders and billers that they may see new messages, in the MCS Claims Processing System, that modifier -59 or the -X{EPSU} modifier is allowed on either column 1 or column 2 codes of the NCCI PTP code edit. This flexibility may improve the efficiency of your coders and billers.
Do not use modifier -59 or the -X{EPSU} modifiers just to push a claim through the MCS Claims Processing System. Only use these modifiers when the documentation in the medical record supports them!
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