The Medicare National Correct Coding Initiative (NCCI) includes edits that define when two (HCPCS/CPT codes should not be reported together.
A correct coding modifier indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.
A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.
One function of these edits is to prevent payment for codes that report overlapping services except in instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.
The CPT manual defines modifier 59 as a distinct procedural service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day.
Modifier 59 identifies procedures/services, other than E/M services and radiation treatment management, which are not normally reported together, but are appropriate under the circumstances. Documentation must support:
A different session,
Different procedure or surgery,
Different site or organ system,
Separate incision/excision,
Separate lesion, or
Separate injury (or area of injury in extensive injuries)
Note: When another already established modifier is appropriate, report it instead of modifier 59. Use modifier 59 only if no other descriptive modifier is available.
Do not report modifier 59 or other NCCI-associated modifiers to bypass an edit unless documentation in the medical record supports its use.
The CMS established four (4) HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported.
XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
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”
For details, including appropriate and inappropriate uses and examples of modifiers 59 and X(EPSU), please refer to the CMS MLN Fact Sheet, Proper Use of Modifiers 59 & –X{EPSU}.
As a reminder, your medical documentation must support the use of modifiers.
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