(updated February 2, 2023)
I’ve been getting a lot of questions about the -59 modifier and the new X modifiers, so I thought I would take some time here to explain the use of these modifiers and to let you know why most insurers, including Medicare, still continue to use the -59 modifier.
Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.
The -59 modifier is the most commonly used and commonly abused modifier. According to 2013 CERT Report data, incorrect -59 modifier usage amounts to a $77 million per year overpayment.
Because of this, CMS believes that more precise coding options are needed to reduce the errors associated with this overpayment.
As a result, CMS established 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.” This modifier should only be used to describe separate encounters on the same date of service.
- XP – “Separate Practitioner.” A service that is distinct because it was performed by a different practitioner.
- XS – “Separate Structure.” A service that is distinct because it was performed on a separate anatomical area.
- XU – “Unusual Non-Overlapping Service.” The use of a service that is distinct because it does not overlap usual components of the main service.
These -X modifiers are intended to provide greater reporting specificity.
Though CMS will continue to recognize the -59 modifier, the Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available.
In some instances CMS may selectively require a more specific – X modifier for billing at high risk for incorrect billing.
Because the X modifiers are different versions of the -59 modifier, it would be incorrect to include both modifiers on the same line.
Though the use of the new modifiers was scheduled to start January 1, 2015, don’t hold your breath. Here’s why:
- Chiropractors are only paid for 98940, 98941 and 98942. None of your adjustment codes would require modifier -59.
- For now, secondary billing for Medicare is uncertain. Secondary (private) payers haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It’s likely they will adopt the same rule sooner or later, so keep an eye out for changes.
- To date, private payers are not requiring the new modifiers. Providers such as BCBS, Aetna, and Cigna haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It is likely that they will in the future so watch for updates from private payers.
Though it is likely that the -59 Modifier days are numbered, until then continue to code as usual, with modifier -59.
The “Compliance Made Easy” program is the most complete course on office compliance and includes how to documentation requirements.
If you have any questions or concerns don’t hesitate to call or email, we’re here to help you.
All The Best,
Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services
