Changes to the 59 Modifier
Written by Editor   
Thursday, October 22, 2015 12:00 AM

The National Correct Coding Initiative (NCCI) edits were developed by the Centers for Medicare and Medicaid Services (CMS).  The NCCI edit program is used by carriers and third party administrators in an effort to thwart abusive billing practices of codes that should not be used together.

For doctors of chiropractic, three common therapeutic procedure codes are identified by the edits when billed with chiropractic manipulative treatment (CMT) codes: 98940, 98941, and 98942. These procedure codes are 97112 neuromuscular re-education, 97124 massage therapy, and 97140 manual therapy.

There are exceptions to the NCCI edits. One is when the 59 modifier is used to indicate to the carrier that a “distinct procedural service” is involved and the procedures should be paid separately. The CMS released new subsets of the 59 modifier in January 2015.

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 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

When another already-established modifier is appropriate, however, it should be used rather than modifier 59. If no further descriptive modifier is available, and the use of modifier 59 best explains the circumstances, only then should modifier 59 be used.

In January 2015, CMS released direction on the use of the X-subset modifiers. The X subsets are expected to have initially only limited effect on chiropractic procedures and billing. Although the X subsets apply only to Medicare billing as of the beginning of 2015, it is expected that the X subsets will be adopted by other carriers because of the data indicating 59- modifier abuse.

The chiropractic manipulative treatment codes (98940, 98941, and 98942) consist of three portions or procedures bundled together. These are the pre-assessment (history), the manipulation, and the post-assessment. These procedures are inherent and cannot be routinely unbundled. If DCs are performing a distinct procedure that is not inherent in the manipulation, then they have to append a modifier to communicate to the carrier that an exception exists.

When performing neuromuscular re-education, massage, joint mobilization, or trigger-point therapy and billing Medicare, the 59 modifier is to be used only as a “last resort.” Instead, one of the following XE, XS, XP, or XU subset modifiers would be more appropriate.

Modifier XE: Separate encounter—the service is distinct because it occurred during a separate encounter.

Modifier XS: Separate structure—the service is distinct because it was performed on a separate organ or structure.

Modifier XP: Separate practitioner—the service is distinct because it was performed by a different practitioner.

Modifier XU: Unusual non-overlapping service—the service is distinct because it does not overlap usual components of the main service.

The XS modifier will most likely be used in most circumstances for 97140, but XU may be most appropriate for 97112 and 97124, as they do not need to be performed on a separate structure. But this depends on guidance from payers.

Check with your local Medicare carrier for further clarification. Do not use these new modifiers for private payers until it is confirmed that they have begun to accept them. Some have stated that they will allow either the 59 modifier, or one of the X modifiers, but not both. Others have indicated that they would like to see the 59 modifier followed by the appropriate X modifier on the same line. Yet other carriers have remained silent.