CMS Says Modifier 59 Needs an Assist

We can all use a helping hand sometimes.  For modifier -59, it is very commonly used and it seems it needs some help doing its job. This code is used to indicate a “Distinct Procedural Service”.  It can be appended to a code in order to clarify that the “subset” service was in fact separate and distinct from the more comprehensive service also performed.disctinct procedural service

Per CMS, that description is considered to be too broad and is frequently used incorrectly in error. It is not always the most appropriate modifier to be used in all circumstances of:

  • Different encounters
  • Different anatomic sites
  • Distinct services


It is also not appropriate to utilize this code to fraudulently override the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edit rules.


Iridium Suite Medical Billing Software has a built in claim scrubber that automatically alerts the user when NCCI edit conflicts occur.  This provides the biller with the ability to review all the applicable medical documentation and make the appropriate choice in adding a modifier when indicated.


This form of double billing for services has been so frequently identified through audits, that CMS is implementing a new more descriptive subset of the -59 modifier that is scheduled to take effect January 1, 2015.  Their goal is both to provide a deeper level of understanding about under which circumstances the NCCI edits should be overridden and as a way to reduce the cases of truly fraudulent coding.

There will be four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers).  Each provides a more clear delineation of the situations in which a code should be indicated as reimbursable.subset of modifier of 59

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, and


XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

proper claim reimbursement


Now is the time to get prepared so you can meet your goal of accurate coding and proper claims reimbursement for the New Year!!