CMS: Modifier 59 will see stricter documentation requirements in 2015
Vol. 2,Issue 6
Modifier 59 is the most widely used and apparently the most “abused” modifier, according to CMS audit data. In response, the agency is taking action, releasing new coding requirements that will be effective Jan. 1, 2015. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with overpayments.
Modifier 59 by CPT definition: “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.” The modifier is required to unbundle codes when two or more non-E/M services are bundled within the National Correct Coding Initiative (CCI) edits. It should only be applied in specific instances, such as when multiple services are billed for different encounters, different anatomical sites, and/or distinct services requiring separate work. The issue being addressed by CMS is the usage of modifier 59 in situations where none of the above apply. CMS has thus established four new subset modifiers to encourage providers to explain the exact intended use when reporting the modifier on a claim.