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Medicare eases up on modifier 59 requirements

You’re going to get a break when you use a distinct procedure modifier such as 59 or XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) to unbundle a coding edit for a Medicare claim. Effective July 1, you will be able to append these modifiers to the column one or the column two code, CMS announced Feb. 15, in CMS 100-20, Change Request 11168.
MCS system maintainers shall update the claim adjudication rules for NCCI PTP edits to allow bypass of an edit with CCMI of “1” if modifiers 59, XE, XS, XP, or XU are appended to either the column one or column two code.
Here’s an example of how this policy could make your billing a little bit easier.
A doctor performs 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa [eg, shoulder, hip, knee, subacromial bursa]; with ultrasound guidance, with permanent recording and reporting) on a patient’s left knee and 64450 (Injection, anesthetic agent; other peripheral nerve or branch) on the patient’s right arm. The peripheral block is bundled into the joint injection, but in this instance the practice could use a modifier to break the edit pair and report both services.
  • Before July 1 – The practice must append the modifier to 64450, the column two code.
  • After July 1 – The practice may append the modifier to 20611 or 64450.
What may be more notable is the inclusion of the X modifiers in the change request. CMS rolled out these modifiers in 2015 to create greater accuracy in coding and reduce abuse of modifier 59. However, CMS soon put plans to make the modifiers mandatory on the backburner. This is the first fresh CMS reference to X modifiers in some time. The change request also suggests that an upcoming MedLearn Matters article will provide more detail.
Blog Tags: CMS
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