Modifier -59 modifications carry big reimbursement impact

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Dr. Freeman takes a closer look at modifier -59, including some of the major concerns all physicians should be aware of, as it will affect claims.
 

coding.doc by L. Neal Freeman, MD, MBA

Over the past several years, numerous initiatives brought forth by Medicare-technically, the Centers for Medicare and Medicaid Services (CMS)-have created major changes in provider reimbursement.  One such action is the development of a new set of specific modifiers that will impact claims previously submitted with modifier -59. 

Modifier -59 is commonly known as the “Bundle Breaking Modifier.”  Although a tremendous number of bundling edits have been established through the National Correct Coding Initiative, it has been possible to break many of the bundles with the -59 modifier.

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The CPT definition of modifier -59 is as follows:

“59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support 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. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

The above definition encompasses a variety of circumstances ranging from “different session” to “separate injury,” and therefore could be considered too broad.  CMS believes this is the case, and has therefore taken action.

Importance of understanding modifier -59

Identification of usage patterns for modifier -59 has been part of The Office of Inspector General’s annual Work Plan many times recently.   Incorrect reporting of modifier -59 has been well documented.  Some data shows reporting error rates approaching 50 percent.  Medicare recognizes that substantial federal savings would result if inappropriate use of this modifier could be curtailed.  The benefit to the program could easily reach hundreds of millions of dollars.

Incorrect unbundling is a form of fragmentation, hence double billing.  Changes that are being implemented by CMS in reporting of modifier -59, by achieving greater detail, will likely eliminate some of the inappropriate reporting.

Beginning January 1, 2015 (implementation date January 5, 2015), these new modifiers should be reported, presuming one of the following specific scenarios applies:

• XE – Separate Encounter. Used to describe services that are separate because they take place during separate encounters.

• XS – Separate Structure. Used to describe services that are separate because they are performed on different anatomic organs, structures or sites.

• XP – Separate Practitioner. Used to describe services that are distinct because they are performed by different practitioners.

• XU – Unusual Non-overlapping Service. Used to describe services that are distinct because they do not overlap the usual components of the main service.

Concerns

CMS’ biggest concern is not with separate encounter or separate structure indications.  Rather, the agency thinks the problem centers upon reporting distinct services when the work of one service has been designated as a subset of another service.

Medicare has instructed it will still accept the -59 modifier.  However, certain codes may be rejected since the more specific modifier will be required for certain services. Since the new modifiers are more specific than modifier -59, they will frequently be the appropriate choice.  CMS has recommended “rapid migration” to use of the specific modifiers.

It is unknown whether the private payers will recognize the new modifiers.  The best way to determine this is to review informational updates from the respective payers, and to contact them individually for any remaining questions.

Another uncertainty exists for the circumstances in which the CPT manual specifically directs use of modifier -59.  For example, in the wound closure section of the CPT manual, the following instruction appears:

“When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 59.”

The new modifier scheme might suggest otherwise, depending on specific circumstances.  The answers to these apparent disparities will likely be worked out over time.

Questions regarding this change as it relates to Medicare are best directed to your local Medicare contractor.  The administration of the policy will probably vary between jurisdictions.

You and your staff should stay constantly monitor changes in the National Correct Coding Initiative edit lists.  The lists are dynamic, and many dollars are lost due to improper/inadequate reporting of related services.

It will be worthwhile to follow developments in this initiative.  The financial impact of inadequate attention could be very sizable.

L. Neal Freeman, MD, MBA, FACS is president of CPR Analysts Inc. (www.cpranalysts.com.) He advises physicians nationally on coding, reimbursement, and practice management. Dr. Freeman is a practicing ophthalmic plastic surgeon and a certified specialist in physician coding. Readers may contact him at nfreeman@cpranalysts.com or 321/253-2166.

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