Payers May Require DCs to Append New Subset Modifiers

Posted on Jan 19, 2015

Payers May Require DCs to Append New Subset Modifiers
Thursday, January 15, 2015 12:32 PM

On December 17th, ACA notified members concerning the new subset of HCPCS modifiers for modifier 59 that were proposed by CMS in August, 2014.

ACA has continued to monitor whether these modifiers will be required by commercial payers, and both United Healthcare and Anthem BCBS have released information as follows:

  • United Healthcare Network Bulletin - January 2015  UnitedHealthcare will continue to recognize modifier 59; however, current procedural terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. In addition, the X {EPSU} modifiers are more selective versions of modifier 59, so it would be incorrect to include both modifiers on the same line. [emphasis added]
  • Anthem Blue Cross Blue Shield December 23 Network E-Update  Important professional reimbursement information. Please see the following corrections to the December 2014 issue of Network Update. Beginning with claims for dates of service on or after January 1, 2015, Anthem (the Health Plan) will consider the new -X {EPSU} modifiers as informational only and will not be used to override an edit until further notice. Please continue your current billing practices until further notice. For further questions, please contact your local Network Relations consultant. [emphasis added]

This time of year, payers will often post 2015 Policy Updates, Reimbursement Guidelines and Network Bulletins; for example some of the November and December Anthem Blue Cross and Blue Shield's newsletters stated that they would be implementing these modifiers. The aforementioned notice states otherwise. This illustrates the importance of checking payer websites weekly, if not daily. If such a notice is received, providers should ascertain whether the payer is requiring use with therapy services as some are selectively choosing the types of services to which this modifier subset will pertain. Meanwhile, providers are advised to continue using modifier 59 according to standard CPT directives.

ACA encourages you and your staff to stay alert to any information on this issue so that reimbursement will not be delayed for your practice. Be sure to only accept guidance from CMS, your MAC, and (if applicable) insurers on if/how/when to use these modifiers. 

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