By Christopher P. Young, Editor, G2 Compliance Advisor
The latest communication from the Centers for Medicare and Medicaid Services (CMS) concerning new modifiers, referred to as X(EPSU), intended to replace the 59 modifier, says that while the new modifiers are available, laboratories and other providers may continue to use the 59 modifier on and after Jan. 1. In MLN Matters SE1503, CMS says the previously released notice in the form of program transmittal R1422OTN (MM8863), was designed mainly for system developers to help them prepare to incorporate the new modifiers in their systems. That goes for laboratory providers as well, but if your laboratory has not completed and tested the system changes required to submit these modifiers, there is apparently a little more time while CMS examines claims submittals to help define the new X(EPSU) modifiers.
According to the MLN Matters article, “Additional guidance and education as to the appropriate use of the new X(EPSU) modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled fashion. That guidance will include additional descriptive information about the new modifiers.”
Laboratories and other providers are told they can use the new modifiers and that they are functional within the CMS systems, meaning they will have the same effect on claims as the 59 itself. Providers would use them according to their interpretation of the published definitions while CMS develops specific guidance for use of the X(EPSU) modifiers.
Laboratories may want to stick to the 59 instead of using the new modifiers because any use of the new modifiers is likely to generate increased scrutiny and CMS has not provided any guidance specific to laboratory use. In addition, laboratories should review their use of the 59 modifier and make certain they can provide documentation of the medical necessity that prompted the use of 59.