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August 2021

Claim editing update coming this year to Medicare Advantage PPO claims with modifier 59

Beginning later in 2021, Medicare Advantage PPO will be updating our edits applied to claim lines when modifier 59 or related “X” modifiers are appended. We’re enhancing our claim editing to promote the appropriate use of modifier 59 and to improve claim payment accuracy.

About Modifier 59
Modifier 59 is used to indicate that a procedure or service was distinct or independent from other services that aren’t normally reported together but are performed on the same day. For our Medicare Plus Blue℠ patients, we’ll no longer automatically allow payment of procedures billed with modifier 59 and related “X” modifiers when billed with a procedure code on the Centers for Medicare & Medicaid Services’ Procedure‑to‑Procedure NCCI List.

This change aligns with CMS guidelines and it’s also consistent with the Department of Health and Human Services Office of Inspector General’s recommendation that payers conduct prepayment reviews of the use of modifier 59.

We’ll provide updates in future communications on when these edits will take effect, along with any other pertinent information.

About the appeal process
The appeal process won’t change. Appeals should continue to be submitted on the Clinical Editing Appeal Form with the necessary supporting documentation. Continue to fax one appeal at a time to avoid processing delays.

Before filing an appeal, validate that you are using modifier 59 appropriately. Examples of correct and incorrect use of modifier 59 are provided in this article** from CMS.

More information
In addition to modifier 59, these enhancements also apply to:

  • 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 nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.