Specific Modifiers for Distinct Procedural Services

Change Request (CR) 8863 notifies MACs and providers that CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services where the second code defines a subset of the work of the first code. Some providers incorrectly consider modifier 59  to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse leading to reviews, appeals and even civil fraud and abuse cases.

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.

At this time 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. However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.