On August 15, 2014, the Centers for Medicare & Medicaid Services (CMS) introduced four new Healthcare Common Procedure Coding System (HCPCS) modifiers that will clarify the use of modifier -59.

The modifier -59 description implies that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Provider specialties and others often use it to override edits found in Medicare’s National Correct Coding Initiative (NCCI), and according to CMS, it is the most widely used modifier in the HCPCS.

The frequency with which the -59 modifier is reported is partly because, as currently defined, this modifier can be used in a wide variety of circumstances, such as identifying different encounters, different anatomic sites, or for distinct services. As a result of a 2013 Comprehensive Error Rate Testing report and a projected $770 million in improper payments, CMS believes it can reduce the incorrect use of this modifier and the subsequent Medicare overpayments with a combination of more precise coding options by the usage of these four new modifiers.

As noted in Pubs 100-02, Transmittal 1422 the four new HCPCS modifiers to define specific subsets of modifier -59, are referred to collectively as -X{EPSU} modifiers:

• 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.

Providers should carefully consider whether or not to use the -59 modifier when a more descriptive modifier is available. CMS may decide to require a more specific – X (EPSU) modifier for billing certain codes it believes are more likely to generate billing errors. For example, a particular NCCI code pair may be designated as payable only with the –XE (Separate Encounter). Providers should be prepared to be more selective in use of modifiers when billing Medicare in the near future.

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