Medicare changing rules for modifiers to override claims edits

Historically, Medicare and other payers that use the National Correct Coding Initiative (NCCI) edits to bundle services provided to the same patient on the same date have required that any modifier used to override an edit must be applied to the “column 2 code” in an edit pair (i.e., the code that would not be paid in the absence of a modifier). That policy, which can sometimes be confusing, is changing.

Effective July 1, Medicare will allow you to append the following modifiers to either code in the procedure to procedure NCCI edits, when a modifier override is allowed:

•    59 – “Distinct Procedural Service”
•    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”
•    XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

Some private payers are following suit. UnitedHealthcare will begin using these modifier rules effective with dates of service on or after July 1.

You’ll still need to recognize when a modifier is appropriately appended to get both services paid in compliance with CPT instruction, payer policy, or both. But you won’t have to worry about which service code to apply it to when you do.

Other modifiers, such as modifier 25, “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service,” should still be appended to the “column 2 code” unless the payer instructs otherwise.

– Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians