Modifier Changes in Medical Billing

Modifier Changes in Medical Billing

There are medical billing changes to go into effect January 1, 2015 regarding the appropriate use of modifier 59. All medical billers, coders, and providers need to be aware of the proper use of this modifier (distinct procedural service).

The Centers for Medicare and Medicaid Services (CMS) release their final ruling regarding modifier 59. Transmittal 1422 CR8863 details new modifiers that are to be used in place of 59. The new modifiers will affect the National Correct Coding Initiative (NCCI) edits, which are used by CMS MAC carriers.

New Distinctive Descriptors

CMS established new HCPCS modifiers that define subsets of modifier 59. This distinct procedural service code will still be recognized until the end of 2014. At that time, CMS will accept either modifier 59 or the more selective X(EPSU) modifier.

However, contractors can require the use of selective modifiers instead of the general 59 modifier for compliance and program integrity. The new distinctive descriptors are:

  • XE Separate Encounter – Service tis distinct because it occurred during another separate encounter.
  • XS Separate Structure – Service is distinct because it was performed on a separate structure or organ.
  • XP Separate Practitioner – Service is distinct because it was performed by a different provider.
  • XU Unusual Non-Overlapping Service – Use of a service because it does not overlap usual components of the main service.

CPT Modifier 59 Reimbursement Guidelines

There are certain guidelines to follow to prepare and work with the modifier changes under CMS guidelines. These include:

  • Use the subset more descriptive modifier EPSU when applicable. CMS will, however, recognize modifier 59 to make sure it is used appropriately.
  • Medical billing professionals should notify providers regarding the new guidelines. The practice management system should be changed so it does not automatically default to modifier 59.
  • Ensure proper documentation for any distinct service, especially when using the new modifiers.

CMS will allow the use of modifier 59, but recognizes that it should only be used when a more descriptive modifier is not available. At present, it is not known if other payers will adopt the new modifiers, but they usually follow CMS protocol. A physician who codes his or her own services should understand how to use the four new modifiers to accurately describe services rendered.

Use of Modifiers

Correct modifier use is an important aspect of medical billing, and when properly done, it cuts down on fraud, abuse, and compliance issues. The federal, state, and private payers report that top billing errors involve incorrect use of modifiers.

Procedure codes can only be modified under specific instances, which is done to give a more accurate description of the service or item rendered. Modifiers are used to add information or alter the description of a service or supply. Proper documentation is necessary to support modifier use.

  • Level I CPT Modifiers – These are two numeric digit codes, which are updated each year by the American Medical Association (AMA).
  • Level II CMS Modifiers – These are two alphabetic digit codes (AA through VP), which are recognized nationwide and updated each year by CMS.

Inappropriate Use of Modifiers

The Multi-Carrier System (MCS) is used by Part B Medicare carriers to process claims. MCS will deny claims as “unprocessable” when the wrong modifier is used or one is inappropriately used. If the procedure code and modifier combination is not right, the biller must make corrections and resubmit the claim.

Having front-end edits in the claim processing system will stop a delay in payment. It may be necessary to process the claim with the phrase “additional documentation available upon request” for the purpose of supporting the use of a modifier. Provision of documentation is often a way to prevent unnecessary claim denials.

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