Coding Corner: Medicare now allows modifier 59 on CCI column 1 or column 2 code

August 15, 2019
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from Deborah Marsh, senior content specialist for AAPC, a training and credentialing association for the business side of health care.

Effective July 1, 2019, Medicare allows placement of modifier 59 and the X{EPSU} modifiers on either the column 1 or column 2 code of a Correct Coding Initiative (CCI) edit pair to bypass the edit. This is a change from the previous rule requiring placement of those modifiers on the column 2 code.

Physician practices need to be aware of this CCI modifier update because it affects Medicare CCI Procedure-to-Procedure (PTP) edits for physicians and practitioners. Medicare has posted MLN Matters R2259OTN and CMS transmittal 2259, CR 11168 to explain the rule change.

Specifics of Medicare’s new CCI modifier rule

For dates of services on or after July 1, 2019, the Multi-Carrier System (MCS), which Part B MACs use to process claims, accepts the following modifiers on either the column 1 or column 2 code to bypass a CCI edit:

  • 59 Distinct procedural service
  • XE Separate encounter, a service that is distinct because it occurred during a separate encounter
  • XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
  • XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
  • XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.

Modifiers XE, XP, XS and XU are known as X{EPSU} modifiers. Medicare accepts these modifiers; you may use them to offer more specific information than modifier 59 provides.

Modifiers 59 and X{EPSU} are not the only modifiers you can use to override an edit. Read more about CCI-associated modifiers in the final section below.

Impact of the CCI rule change

The rule change may result in reduced claim rework. Before this update, practices that appended modifier 59 or an X{EPSU} modifier to the column 1 code of an edit had to correct the claim by switching the modifier to the column 2 code before receiving reimbursement.

Other Medicare CCI rules have not changed, however. For example, if the edit has a modifier indicator of 0, Medicare will not allow you to override the edit. The edit must have a modifier indicator of 1 for you to consider using a modifier to bypass the edit. You also must be sure that documentation and clinical circumstances support overriding the edit and that you follow Medicare rules for modifier use.

Non-Medicare payors may have their own rules for appending modifiers and overriding edits, so be sure you’re aware of payor-specific preferences.

Medicare CCI edit essentials

To understand the rule change, you need to understand CCI edits. Each CCI PTP edit has a column 1 code and a column 2 code. The codes may be CPT® or HCPCS Level II codes. Medicare does not expect you to report both the column 1 and 2 codes in an edit pair for the same patient, provider and date of service. Possible reasons include coding rules or anatomic impossibility. Medicare updates CCI edits each quarter.

For example, in the third quarter of 2019, CCI has a PTP edit for column 1 code 93015 (Cardiovascular stress testelectrocardiographic monitoring …) and column 2 code 93040 (Rhythm ECG …). The 93015 descriptor states that it includes ECG, so CCI bundles ECG code 93040 into that more extensive 93015 service.

Medicare will not pay for the column 2 code if you report both codes in the edit pair together. But, as explained above, if an edit has a modifier indicator of 1, you may bypass the edit by appending a modifier to show that you’re submitting codes for two separately reportable services or supplies.

Below is the complete list of CCI-associated modifiers, as published in Medicare’s 2019 NCCI Policy Manual for Medicare Services, chapter 1, section E:

  • Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
  • Global surgery modifiers: 24, 25, 57, 58, 78, 79
  • Other modifiers: 27, 59, 91, XE, XS, XP, XU

To continue the ECG example, the 93015/93040 edit has a modifier indicator of 1, so you can bypass the edit if, for instance, the services are at separate encounters. Modifier 59 or XE may be appropriate, depending on your payor. You should use the most specific modifier(s) possible to provide the details of the encounter and support separate coding and reimbursement.


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