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New "X" Modifiers from CMS Effective January 1, 2015

Wednesday, January 7, 2015   (0 Comments)
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United Heatlhcare will also be asking providers to use these new modifiers.

 

CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows:

  • 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
  • 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 modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line. The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. 

As a default, 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, these modifiers are valid modifiers even before national edits are in place, so contractors 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.

 

Please find more helpful information in the AOA's latest Oto's Scope publication!


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