Medicare Advisory Liaison

Modifier 59 – Distinct Procedural Service

Modifier 59 is defined 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 E&M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E&M services, that 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 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 physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E&M service performed on the same date, see modifier 25.

Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as X[EPSU] modifiers) to define specific subsets of the 59 modifier:

  • 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.

CMS will continue to recognize the 59 modifier, but notes that CPT instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the XE separate encounter modifier but not the 59 or other X(EPSU) modifiers. The X(EPSU) modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

Source: NGS Website

OIG Adds Podiatry Services to 2020 Work Plan

The OIG recently added podiatry and related ancillary services to their Work Plan.

While routine podiatry services like nail trimming and callus/corn removal are generally not covered by Medicare Part B, some medically necessary services may be covered if they meet one of the following exceptions:

  • Performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds or infections
  • Mycotic nails (toenail infections)
  • Treatment of foot warts
  • Performed in the presence of another systemic condition(s) such as diabetes

In addition, evaluation and management services (E/M) are generally not covered the same day as other podiatry services UNLESS the E/M service is a significant, separately identifiable service above and beyond the routine evaluation that is included in the podiatry service being performed.

The OIG is also looking at ancillary services ordered by podiatrists (labs, x-rays, prescription drugs and therapy) which are permitted as long as the service is deemed medically necessary.

Prior findings of inappropriate payments for these types of services has led the OIG to add podiatry to the current Work Plan. The OIG will specifically review Part B payments to determine whether podiatry and ancillary services were medically necessary and provided in accordance with Medicare requirements.

CMS has issued a helpful Fact Sheet regarding podiatry services that can be can be accessed here.

Chapter 15 of the Medicare Benefit Policy Manual also outlines coverage criteria and the details can be found here at section 290.

We recommend you review the Work Plan and conduct proactive audits of identified known risks that are applicable to your organization. HBE’s team of experts is available to assist you with these audits and any necessary education and training.

The OIG Work Plan can be found here.

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