Instructions for Codes With Modifiers (A/B MACs (B) Only)

20.9.1.1 - Instructions for Codes With Modifiers (A/B MACs (B) Only) (Rev. 13216; Issued:05-09-25; Effective: 06-03-25; Implementation:06-03-25) A. General MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. All line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI PTP edits. If the CCMI of a PTP edit is “0”, the Column Two code is not eligible for payment even if an NCCI PTP-associated modifier is appropriately appended to one of the codes. If the CCMI of a PTP edit is “1”, the edit may be bypassed and the Column Two code of the edit may be eligible for payment if an NCCI PTP- associated modifier is appropriately appended to one of the codes. If the 2 codes of a code pair edit have the same NCCI PTP-associated anatomic modifier, the edit will not be bypassed unless an additional NCCI PTP-associated modifier is appended to 1 of the codes indicating the reason to bypass the edit. The use of modifiers that are not NCCI PTP-associated modifiers shall not bypass an NCCI PTP edit. NCCI PTP-associated modifiers are the following: Anatomic modifiers : E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79 Other modifiers: 27, 59, 91, XE, XS, XP, XU B. Modifiers 59 or XE, XP, XS, XU Modifiers 59 or XE, XP, XS, XU and other NCCI PTP-associated modifiers shall not be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier that is used. Find further information on modifiers 59 or XE, XP, XS, XU in the Coding Policy Manual available on the CMS website. Use of modifiers 59 or XE, XP, XS, XU does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers 59 or XE, XP, XS, XU. Modifiers 59 or XE, XP, XS, XU shall not be used with the following codes: • 77427 Radiation treatment management, 5 treatments • Evaluation & Management (E&M) services When a provider or supplier submits a claim for any of the codes specified above with modifiers 59 or XE, XP, XS, XU, the A/B MAC must process the claim as if the modifier were not present. In addition to those messages specified in §20.9.1 above, A/B MACs shall convey additional messaging per instructions in Pub. 100-09, Chapter 6 and Pub. 100-04, Chapter 22. Examples of appropriate use of modifiers 59 and XE, XP, XS, XU can be found in the Fact Sheet Proper Use of Modifiers 59, XE, XP, XS, & XU. 1. Modifier 59 or XE are used appropriately when the procedures are performed in different encounters on the same day. 2. Modifier 59 or XP are used appropriately when the procedures are performed by different practitioners. 3. Modifier 59 or XS are used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. 4. Other specific appropriate uses of modifiers 59 or XE, XU. There are 3 other limited situations in which 2 services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter. a. Modifier 59 or XE is used appropriately for 2 services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifiers 59 or XE that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If 2 timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine the unit of service for both codes), modifier 59 may be used to identify the services. b. Modifier 59 or XU is used appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When a diagnostic procedure precedes a surgical procedure or on-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention; and d) it is not specifically prohibited. If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately. c. Modifier 59 or XU is used appropriately for a diagnostic procedure, which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non- surgical therapeutic procedure, it should not be reported separately. 5. Modifiers 59 or XE, XP, XS, XU are used inappropriately if the basis for their use is that the narrative description of the 2 codes is different. C. Modifier 91 Modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day when appropriate. If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MUE Adjudication Indicator (MAI) equal to “1”) appropriate use of CPT modifiers (i.e., 59 or XE, XP, XS, XU, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim. This modifier indicates to the Medicare contractors that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier must not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results. For example, if a laboratory performs all tests included in a panel of laboratory tests and repeats one of these component tests as a medically reasonable and necessary service on the same date of service, the HCPCS/CPT code corresponding to the repeat laboratory test may be reported with modifier 91 appended. D. Reserved for future use E. Coding for Noncovered Services and Services Not Reasonable and Necessary For information on this topic, see the Claims Processing Manual, Chapter 1 and MLN Booklet: Medicare Advance Written Notices of Noncoverage ICN 006266. Use of HCPCS Code A9270 HCPCS code A9270 (Non-covered item or service), will not be accepted under any circumstances for services or items billed to A/B MACs. However, in cases where there is no specific procedure code for an item or supply and no appropriate Not Otherwise Classified (NOC) code available, A9270 must continue to be used by suppliers to bill DME MACs for statutorily non-covered items or supplies and items or supplies that do not meet the definition of a Medicare benefit. Claims Processing Instructions At A/B MAC and DME MAC discretion, claims submitted using the GY modifier may be auto denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an invalid modifier and therefore unprocessable. Effective for dates of service on and after July 1, 2011, A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their websites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.