CCI Modifiers: July 1 Update to Modifier 59 Rule Is Now in Force … and More

procedure coding and Medicare modifier 59 rule for CCI

Modifiers are the key to overriding Correct Coding Initiative (CCI) edits, so let’s give them the attention they deserve. We’ll start with a recent rule update and move on to helpful hints about CCI-associated modifiers in general.

Which CCI edits? Our focus here will be Medicare CCI Procedure-to-Procedure (PTP) edits for physicians and practitioners.

Do You Dare to Put Modifier 59 on Column 1 Code?

First up, did you remember that Medicare no longer requires you to append modifier 59 or X{EPSU} modifiers to the column 2 code in a CCI edit pair?

Details: Effective July 1, 2019, the Multi-Carrier System (MCS), the system Part B MACs use to process claims, allows 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).

Previously, the rule was to use those modifiers on the column 2 code. You can review both MLN Matters R2259OTN and CMS transmittal 2259, CR 11168 for the official announcements.

Don’t forget: The edit must have a modifier indicator of 1, not 0, for the modifier to bypass the edit. More on that below.

Brush Up on CCI Modifier Basics for Better Coding

You’ve got CCI on the brain now, so why not refresh your knowledge of CCI modifiers in general? You can get a good overview in chapter 1, section E, of the NCCI Policy Manual for Medicare Services available on Medicare’s National Correct Coding Initiative Edits page (or linked on the CCI edits checker of your TCI SuperCoder coding package). Here are the areas to watch.

Compliance: The big rule to keep in mind is that you should never append a modifier to a code solely to override an edit. Documentation and clinical circumstances must support your choice to append the modifier and report both codes together. You’ve also got to be sure your use of the modifier follows Medicare’s rules. For instance, you may need to confirm you’re coding procedures performed at separate encounters or at separate anatomic locations to support separate reporting and payment.

Allowed modifiers: The modifiers you may use to override a CCI edit are below:

  • 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.

Modifier indicators: When a PTP edit has a modifier indicator of 0, you cannot bypass the edit. Medicare will not allow it. As we mentioned in the previous section, you need to see a modifier indicator of 1 to consider overriding the edit by using a CCI modifier.

What About You?

Will you continue to use modifier 59 on the column 2 code? What rules do you have to follow for modifiers and code edits for payers other than Medicare?

About Deborah Marsh

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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