News Flash: Updated Guidance on 59 and X Modifier Use

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced a change to the way the agency will process modifier 59 and the X modifiers on provider claims. Previously, it would only unbundle NCCI edit pairs if providers submitted the appropriate modifier on the column two code. However, as this resource explains, there were times when it seemed less awkward for billers to affix the modifier to the column one code (usually, “when the column 1 code carrie[d] less relative value units (RVUs) than the column 2 code”). However, CMS would not unbundle the codes in those cases, and billers had to correct the associated claims and submit them for reprocessing, which resulted in additional costs for all parties.

In a “billing-friendly” maneuver, beginning July 1, 2019, CMS will unbundle NCCI edit pairs when providers attach the appropriate modifier (59, XE, XS, XP, or XU) to either the first-column or second-column code (assuming, of course, that the situation warrants the use of one of these modifiers). Please note that while some Medicaid programs, commercial payers, and Medicare Advantage payers may follow suit, this change does not necessarily affect them, which is why the above-cited resource recommends contacting all non-CMS payers to determine where they stand. The resource also notes that this is a good time to inquire as to whether your other payers will accept the X modifiers—because, “recently some non-Medicare payers, such as Horizon Blue Cross Blue Shield, have indicated that they recognize these modifiers.”

Have more modifier questions? Check out this resource, this article, or this modifier 59 decision chart. Can’t find what you’re looking for? Feel free to leave your question in the comment section below—and we’ll do our best to find you the answer.