Four new HCPCS modifiers will be available for use beginning in 2015, according to a recent announcement by the Centers for Medicare and Medicaid Services (CMS).  Known collectively as the –X{EPSU} Modifiers, they will be used to define specific subsets of the CPT Modifier -59 for a “Distinct Procedural Service”.  The new modifiers are intended to offer more precise coding options that will allow practices to avoid potential payment delays, audits and reviews associated with modifier -59.  CMS says that -59 is the most widely used modifier, covering a wide variety of circumstances such as to identify different encounters, different anatomic sites and distinct services.  Because modifier -59 is so broadly defined, it is often used incorrectly and inappropriately.

One use of modifier -59 is related to the Multiple Procedure Payment Reduction (MPPR) as described in our articles Radiology Billing - Don't Lose Legitimate Revenue to the MPPR and How New MPPR Rules Affect Your Radiology Practice Revenue.  Under the new system, HCPCS Modifier XE (Separate Encounter, a service that is distinct because it occurred during a separate encounter) would be used for this purpose instead of CPT Modifier -59.  The other modifiers in this series are:

• 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.

Radiologists will encounter a variety of situations where the new modifiers can be used.  For example, 

• CT of the head (CPT 70450) performed on the same date of service as a CTA of the head (CPT 70496) would be billed using the HCPCS Modifier XE (Separate Encounter).

• Celiac imaging (CPT 75726) performed as part of an interventional procedure on the same date of service as Superior Mesenteric imaging (CPT 75726) would be billed using the HCPCS Modifier XS (Separate Structure).

• Multiple fine needle aspirations of the breast (CPT 10022), typically involving both left and right breasts, would be billed using HCPCS Modifier XS (Separate Structure).

• Extremity ultrasound (CPT 76882) performed on the same date of service as a Duplex Doppler of the extremity (CPT 93971) would be billed using the HCPCS Modifier XP (Separate Practitioner) if two different physicians interpret them.

CMS will continue to recognize modifier -59, but they note that it should not be used when a more descriptive modifier is available and that it should not be used in conjunction with the new –X{EPSU} modifiers.  In some selective instances a more specific –X{EPSU} modifier may be required by CMS for billing certain codes or code combinations that are at high risk for incorrect billing. 

These new –X{EPSU} modifiers are being issued by CMS for Medicare claims. However, as we pointed out in the latter of our two articles, insurance payers other than Medicare are beginning to adopt MPPR rules in their own payment policies.  It remains to be seen whether they will also allow practices to use these new modifiers to more accurately describe a variety of billing situations.

Now is the time to begin getting ready for these new modifiers in order to ensure that your payments are not delayed.  CMS says that they may be used even before national edits are in place, and in some localities the Medicare carrier may require early adoption.  Your billing systems will need updating to include the new codes, and your coding team must be ready to identify situations where these more specific modifiers will apply.  Physicians’ documentation should include information that will allow coders to distinguish which modifier is applicable.  Careful use of these modifiers can potentially reduce your claims processing time and enhance practice revenue.  Whether you handle billing and coding internally, or via an outsourced solution, be sure that your team has the resources and know-how to handle these changes come 2015.

Related articles:
Radiology Billing - Don't Lose Legitimate Revenue to the MPPR
How New MPPR Rules Affect Your Radiology Practice Revenue