Effective Date: March 15, 2021

Purpose:

In accordance with CMS National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edit guidelines, Horizon NJ Health shall consider for reimbursement a procedure or service that is distinct or independent from other services performed on the same day by the same provider when NCCI edit code pairs with a ‘superscript’ of zero, or a modifier allowance indicator of zero are appropriately appended with Modifiers 59 or X{EPSU} to the paid or denied code.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Modifier -59:

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service

Policy:

Horizon NJ Health accepts the submission of distinct procedure modifiers for claims processing, but use of such modifiers does not always determine reimbursement eligibility. Modifiers 59 and X{EPSU} are important to the adjudication of the claim because they may result in the override of procedure unbundling edits in Horizon NJ Health’s claims editing systems as described in more detail below.

Documentation is not required for a claim to be processed when modifier 59 or X{EPSU} is appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. Horizon NJ Health follows CPT coding rules and guidelines in requiring that documentation must support:

1. Procedure Unbundling: is defined as using two or more procedure codes to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. Procedure unbundling edits within the Horizon claims systems include three components: Incidental, Mutually Exclusive, and Rebundling. These edits generally function as follows:  
   • When modifier 59 or X{EPSU} are appended to a reported procedure code, our claims editing systems will override most incidental, mutually exclusive, and rebundling denials, and allow separate reimbursement for that procedure.
   • The incidental, mutually exclusive, and rebundling edits are not overridden when a different diagnosis is submitted, with a line item procedure code, without a modifier that identifies a distinct procedural service.
   • However, a different diagnosis alone does not justify the use of modifier 59 or X{EPSU}.
   • Unlisted procedures are not affected by modifier 59 or X{EPSU}.
2. Reporting and Documentation Rules and Criteria for Modifier 59: The reporting of modifier 59 or X{EPSU} by a provider must follow Horizon NJ Health’s requirements for correct coding, as follows:  
   • Horizon NJ Health requires that modifier 59 or X{EPSU} must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits
   • We follow CPT coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. 2”
   • Modifier 59 should only be used if no more descriptive modifier is available, such as X{EPSU}.
   • Modifier 59 should not be appended to the same claim line item as X{EPSU}

   Documentation is not required for a claim to be processed when modifier 59 or X{EPSU} is appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. Horizon NJ Health follows CPT coding rules and guidelines in requiring that documentation must support:

   • a different session or patient encounter
   • a different procedure or surgery
   • a different anatomical site or organ system
   • a separate incision/excision
   • a separate lesion
   • a separate injury

   The following example indicates the appropriate use of modifier 59 or X{EPSU} when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported:

   • A single view chest x-ray (71045) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71045 will be denied separate reimbursement.
   • When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 or XE to CPT 71045 is warranted to signify that a separate and distinct service was performed. (Modifier 59 should follow modifier 26, if services are done in a facility setting.) Modifier 59 or XE will override the procedure unbundling edit and 71045 will be eligible for separate reimbursement.
3. Exceptions to Overrides : Horizon NJ Health has determined that there are certain circumstances which are exempt from a modifier overriding an unbundling edit, or that there are circumstances in which appending modifier 59 or X{EPSU} to a code is inappropriate.

Horizon NJ health will not consider for reimbursement the following codes when billed with the following support codes, regardless of what modifiers listed here are submitted on the claim.

The following is a list of some, but not all, of the circumstances in which appending a distinct procedural service modifier to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement:

Procedure:

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services