Modifier Coding Change
Medicare is changing the use of the 59 modifier (Distinct Procedural Service). This modifier is the most used modifier and so has been targeted by CMS for review as it is suspected to be associated with abuse.
Modifier 59 is used on Medicare and some private payer claims to indicate that a service (CPT code) is separate and distinct from another service with which it is usually considered bundled. (For example, 97140 and 97530: Modifier 59 is required to be submitted along with 97530 to indicate this was a distinct service from 97140.) It can be used to indicate different encounters, anatomic sites and distinct services. CMS suspects that the most common incorrect use of the modifier is to define a distinct service.
CR8863 explains that there will be four new HCPCS modifiers to define the subsets of modifier 59. These are termed X{ESPU} modifiers. These should be used in place of 59 when applicable.
XE: Separate Encounter: distinct service that happened during a separate encounter on a given date of service.
XS: Separate Structure: the service was performed on a separate organ or structure on a given date of service
XP: Separate Practitioner: the service is distinct because it was performed by a different practitioner on a given day of service.
XU: Unusual Non-Overlapping Service: The service is distinct and doesn’t overlap the usual components of the main service.
Although CMS will continue to accept the 59 Modifier, individual MACs may selectively require the more specific two-letter modifier in place of the 59 modifier before the January 5, 2015 implementation date.
The Legislation & Reimbursement Division recommends evaluating your use of modifier 59 and implementing the new system immediately.
Fingerprint Background Check Scheduled to Begin August 6, 2014
On August 20, 2014, Medicare released the following information in SE1427.
This applies to all individuals with a 5% or greater ownership interest in a provider or supplier that is in the High Risk category OR has submitted an initial enrollment application to be a DME provider. (Current OT DME providers are Limited risk and PT DME providers are Moderate risk)
The fingerprint-based background check began Aug. 6, 2014 and will be conducted in phases. Providers and suppliers will be notified of the requirement from their MAC.
If you receive the notice, you have 30 days to be fingerprinted. The provider will be required to be fingerprinted only once, but CMS reserves the right to request additional fingerprints if needed.
If you are contacted to be fingerprinted, you should contact ACCURATE BIOMETRICS of Chicago at 866-361-9944 or www.cmsfingerprinting.com prior to being fingerprinted to be sure the fingerpint results are accurately submitted to the FBI and CMS.
If this is an initial application, the MAC will not begin processing until the fingerprint background check is complete.