2015 Brings Changes to Modifier 59

Modifier -59 is one of the most well known and used modifiers, because it has the potential to have a large impact on your reimbursement from health insurance companies. Because of its popularity (and often misuse), CMS has rolled out 4 new modifiers that essentially replace modifier 59.

What is Modifier 59?

It is defined in the CPT manual as a “Distinct Procedural Service.” It allows the provider to indicate that a procedure or service should be considered separate from another during the same encounter. This is only necessary on codes that are usually considered bundled services. For example:

CPT code 97140 (manual therapy) is usually bundled with CPT code 98940 (CMT, spinal).  When the manual therapy is performed as a separate service for a separate issue (diagnosis), then it can be shown by appending modifier -59 to the CPT code 97140.

This makes both codes payable rather than just the one. This also, of course, needs to be supported by the medical record.

What are the Changes?

CMS has created 4 new modifiers as subsets to modifier -59 that are intended to ultimately take the place of modifier -59. They are more specific, and allow the provider to more specifically indicate why the service is separately identifiable from another.

  1. XE – Separate Encounter
  2. XS – Separate Organ/Structure
  3. XP – Separate Practitioner
  4. XU – Unusual Non-Overlapping Service

How to Implement

The modifiers became effective January 1, 2015, and CMS is encouraging immediate use but is also still accepting modifier -59. It is also important to note that private insurance carriers may not yet be accepting them. Anthem Blue Cross has stated they will accept them for dates of service 1/1/15 and later, but they will not be accepted until the system update in February. It is important to check with your contracted carriers before making the switch, but equally as important to ensure a plan is in place.

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