Centers for Medicare/Medicaid (CMS) frequently deny claims for incorrect use of evaluation management (E/M) codes. Medical necessity and proof that the service was provided are important for doctors to understand. Audits look for claims that consistently use higher than normal codes compared to similar providers. Misuse of codes is targeted for audit.
In 2015, new modifiers are now required for coding/billing. Sub-modifiers are also used to describe specific service(s) performed. For instance, modifier -59 is used to support an entirely different procedure, or site, organ, incision or excision, etc., which are unusual when provided on the same day. The new modifier is -51 to describe multiple procedures that are done on the same day. If the service/procedure is bilateral, -50 is used.
Also, Medicare has established four new modifiers – XE, XS, XP, and XU – that may be used in lieu of modifier -59. The codes are more specific and become effective January 1, 2015.
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Modifier XE
Separate Encounter: A service that is distinct because it occurred during a separate encounter.
Modifier XP
Separate Practitioner: A service that is distinct because it was performed by a different practitioner.
Modifier XS
Separate Structure: A service that is distinct because it was performed on a separate organ/structure.
Modifier XU
Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service.
CMS estimates paying over $770 million in claims in 2015 and misuse will be scrutinized to deny or recover overpayments and penalties assessed for misuse of $10,000 per occurrence.
For a full understanding of the law and provider-patient rights and responsibilities is in this manual:
CMS Regulations at the CMS website.