note: should you have landed here as a result of a search ... · remittance advice remark code...

NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

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RAILROAD MEDILatCAest PRart B NewE As fDor RVIailroad MedicarSORYe What’s Inside...

AdministrationGet Your Medicare News Electronically .................................................................................3 CMS Quarterly Provider Update

Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana

.............................................................................................5 Provider Customer Service Center Training and Closure Dates ..............................................6 Railroad Medicare’s online “PTAN Lookup and Request Tool” .............................................7 Medicare Beneficiary Identifier (MBI) Look-up Tool .............................................................8 New Railroad Medicare Cards and Numbers .......................................................................10

Islands Claims ...................................................................................................................12 Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the

Qualified Medicare Beneficiary (QMB) Program ..............................................................17 New Patient Office or Other Outpatient Visits eCBR Now Available ...................................19 Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories

and Codes ..........................................................................................................................20 Proper Use of Modifier 59 .....................................................................................................22 Additional Processing Instructions to Update the Standard Paper Remit (SPR) ...................29 Claim Status Category and Claim Status Codes Update .......................................................31

Drugs and BiologicalsQuarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological

Code Changes – July 2019 Update.....................................................................................33

EducationEducational Events Where You Can Ask Questions ..............................................................35

Electronic Data Interchange (EDI)Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC),

Medicare Remit Easy Print (MREP) and PC Print Update ................................................36

Continued >>

palmettogba.com/rr

The Medicare Advisory contains coverage, billing and other information for Railroad Medicare. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The Railroad Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at https://www.PalmettoGBA.com/rr.

CPT only copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not con-tained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2018 American Dental Association (ADA). All rights reserved.

June 2019 Volume 2019, Issue 6

https://www.PalmettoGBA.com/rrhttps://www.PalmettoGBA.com/rr

Fee Schedules and Reimbursement Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2019 Update .......................38 Medicare Physician Fee Schedule Database File Record Layout .................................................................................41

Medicine Documentation of Evaluation and Management Services of Teaching Physicians ......................................................42 International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National

Coverage Determination (NCDs) ..............................................................................................................................43

Chiropractic Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and

Subsequent Visits .....................................................................................................................................................45 Use of the AT modifier for Chiropractic Billing (New Information Along with Information in MM3449) ................52 Educational Resources to Assist Chiropractors with Medicare Billing .......................................................................56

Laboratory Re-implementation of the AMCC Lab Panel Claims Payment System Logic .............................................................61 Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge

Payment .....................................................................................................................................................................63

Etcetera MLN Connects ..............................................................................................................................................................68

CMS Provider Minute Videos

The Medicare Learning Network has a series of CMS Provider Minute Videos (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.html) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting documentation. Check the site often as CMS adds new videos periodically to further help you navigate the Medicare program.

CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2018 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

2 6/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.html

Get Your Medicare News Electronically The Palmetto GBAMedicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: • Medicare incentive programs • Fee Schedule changes • New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv: Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

eServices Eligibility eServices, by Palmetto GBA, allows you to search for patient eligibility, which is a functionality of HETS. HETS requires you to enter beneficiary last name and Medicare ID Number, in addition to either the birth date or first name. See options below:

• Medicare ID Number, Last Name, First Name, Birth Date • Medicare ID Number, Last Name, Birth Date • Medicare ID Number, Last Name, First Name

For more information about eServices and the many services it offers, please visit our website at http://www.PalmettoGBA.com/eServices.


3 6/2019

http://tinyurl.com/PalmettoGBAListservhttp://www.PalmettoGBA.com/eServices

Medicare Learning Network® (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims

processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.html • MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To

access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”

• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources: • MLN Publications List: contains the electronic versions of the downloadable publications. These products

are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service: 1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or

Unsubscribe’ link under the ‘Options’ tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].


4 6/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-lmailto:[email protected]

CMS Quarterly Provider Update The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to: • Inform providers about new developments in the Medicare program • Assist providers in understanding CMS programs and complying with Medicare regulations and instructions • Ensure that providers have time to react and prepare for new requirements • Announce new or changing Medicare requirements on a predictable schedule • Communicate the specific days that CMS business will be published in the ‘Federal Register’

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.

We encourage you to bookmark the Quarterly Provider Update Web site at www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. html and visit it often for this valuable information.


5 6/2019

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index

Provider Customer Service Center Training and Closure Dates

The Centers for Medicare & Medicaid Services (CMS) and the Railroad Retirement Board (RRB) have approved the RRB Specialty Medicare Administrative Contractor (RRB SMAC) to close up to eight hours per month for provider Customer Service Advocates (CSAs) training and/or staff development. The goal is to help CSAs improve the consistency and accuracy of their responses to provider questions; enhance their awareness and understanding of Medicare policies and issues; and facilitate CSAs’ retention of the facts of their training by increasing its frequency.

When our CSAs participate in training and developmental sessions on Thursdays of each month, you may use our online provider portal called eServices. eServices

provides claim status, duplicate remittances, patient eligibility and much more. Register now at https://www.PalmettoGBA.com/eServices. Please refer to the training schedule below for specific closure dates and times.

Date May 27, 2019 June 6, 2019 June 13, 2019 June 20, 2019 June 27, 2019 July 4, 2019 September 2, 2019 October 14, 2019 November 11, 2019 November 28, 2019 November 29, 2019 December 24, 2019 December 25, 2019

Phones Closed Office closed / Memorial Day PCC closed for training / 2:30 p.m. to 4:30 p.m. ET PCC closed for training / 2:30 p.m. to 4:30 p.m. ET PCC closed for training / 2:30 p.m. to 4:30 p.m. ET PCC closed for training / 2:30 p.m. to 4:30 p.m. ET Office closed / Independence Day Office closed / Labor Day PCC closed / Columbus Day PCC closed / Veterans Day Office closed / Thanksgiving Office closed / Thanksgiving Office closed / Christmas Eve Office closed / Christmas Day

Please note that we will attempt to provide advance notice of any changes to the above training schedule via the website, IVR features and automatic email notices.

If you have not already done so, we encourage you to sign up for automatic email notices of updates to our website. Subscribing to this listserv is the fastest way to find out about Medicare changes that may affect you. There is no charge for the service, and we will not share your email address with others. To register, go to Email Updates at https://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm.

Continued >> CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2018 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

6 6/2019

https://www.PalmettoGBA.com/eServiceshttps://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm

If you have questions, please call our Provider Contact Center at 888-355-9165 and select Option 5. Customer Service Advocates are available between the hours of 8:30 a.m. to 4:30 p.m. for all time zones, with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT. Our eServices portal is available 24/7 with the exception of claims, remittance, and financial data, which is available from 8 a.m. to 7 p.m. Monday through Friday. You may access eServices at http://www.PalmettoGBA.com/eServices.

eDelivery Reminder: Are You Getting Your Greenmail?

Palmetto GBA would like to remind providers that you have the option to receive letters electronically through eServices. Gaining access to these letters is a simple process! To start receiving your Medicare letters, such as Medical Review Additional Documentation Request (ADR) letters and first level

appeal Medicare Redetermination Notices (MRNs) electronically, you must be signed up for our eServices online provider portal. Once you have signed into eServices, select the Admin tab, next you can choose your eDelivery preferences. Just click the drop down box to choose eDelivery of the letters you would like to receive via greenmail. You can also select “User Email Notification” to start receiving emails when your letters are available in eServices for you. Selecting this choice is so easy and allows you to receive your letters faster!

Once you have chosen the eDelivery option, all of the letters you selected will come to you electronically, even if you sent in your request via fax or mail.

Railroad Medicare’s online “PTAN Lookup and Request Tool”

Providers can now obtain their existing Railroad Medicare Provider Transaction Access Number (PTAN) or request a new Railroad Medicare PTAN through our “PTAN Lookup and Request Tool” at http://www.PalmettoGBA.com/RR/PTAN.

Please review the following resources before using the PTAN Tool: • Using Railroad Medicare’s online “PTAN Lookup and Request Tool”

https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Medicare~Re-sources~Provider%20Enrollment~Articles~AK7K447304?open

• Railroad Medicare PTAN Lookup and Request Tool FAQs https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~AXCNMG2662


7 6/2019

http://www.PalmettoGBA.com/eServiceshttp://www.PalmettoGBA.com/RR/PTANhttps://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Medicare~Re-sources~Provider%20Enrollment~Articles~AK7K447304?openhttps://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Medicare~Re-sources~Provider%20Enrollment~Articles~AK7K447304?openhttps://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Medicare~Re-sources~Provider%20Enrollment~Articles~AK7K447304?openhttps://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~AXCNMG2662

Medicare Beneficiary Identifier (MBI) Look-up Tool The Medicare Beneficiary Identifier (MBI) Look-up tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. The MBI Look-up tool will only return an MBI if the new Medicare card has been mailed to avoid potential confusion if the MBI is used before the beneficiary receives their new Medicare card.

As background, the New Medicare Card Project, was established in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which mandates the removal of the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) from Medicare cards by April 2019. CMS began mailing new Medicare cards with the MBI on April 2, 2018. The Railroad Retirement Board mailed new Medicare cards with the MBI to all Railroad Medicare beneficiaries in June 2018.

From April 1, 2018 to December 31, 2019, CMS will offer a transition period during which the system will accept both HICNs and MBIs on Medicare transactions (including eligibility requests and claims) for beneficiaries in the Medicare program prior to April 1, 2018 (i.e., those who received a HICN on their Medicare card). Note: Providers should not submit both numbers on the same transaction.

Beginning in January 2020, physicians may only use MBIs, with limited exceptions.

When the new Medicare card is mailed to people with Medicare, you will be able to use the eServices MBI Look-Up Tool to obtain a patient’s MBI. To submit an inquiry you must do the following: • Once logged into eServices, click on the MBI LOOKUP tab located in the header of the portal • Complete the required* fields:

• Beneficiary’s Last Name • First Name • Date of birth and • Social security number. NOTE: The social security number must be in the XXX-XX-XXXX format

• To meet our CAPTCHA requirements, you must select the I’M NOT A ROBOT checkbox • Click SUBMIT INQUIRY


8 6/2019

g p

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Figure 1: MBI Lookup Tab

Look-Up Tool Status Results If the inquiry successfully returns an MBI, the screen will refresh with the data at the bottom.

Figure 2: MBI Lookup Successful Response Screenshot

In the event that your MBI lookup request does not result in a successful response, eServices will display error messages to assist you. If any required fields are left blank or are not in a proper format, a message will appear advising you which fields to correct.

Figure 3: MBI Lookup Unsuccessful Response Screenshot

Ch eck the CMS New Medicare Card Project Outreach & Education webpage at https://www.cms.gov/Medicare/ New-Medicare-Card/Outreach-and-Education/Outreach-and-education.html and the Medicare Beneficiary Identifier (MBI) Look-up Tool Clarification article at https://www.cms.gov/Outreach-and-Education/Outreach/ FFSProvPartProg/Downloads/2018-05-17-eNews.pdf for additional information.


9 6/2019

https://www.cms.gov/Medicare/ New-Medicare-Card/Outreach-and-Education/Outreach-and-education.htmlhttps://www.cms.gov/Outreach-and-Education/Outreach/ FFSProvPartProg/Downloads/2018-05-17-eNews.pdf

New Railroad Medicare Cards and Numbers All Railroad Medicare beneficiaries have been mailed their new Railroad Medicare cards with their new Medicare Beneficiary Identifiers (MBIs). MBIs are ‘non-intelligent’ numbers made up of 11 characters of numerals and capital letters. MBIs do not contain the letters B, I, L, O, S, and Z to avoid confusion between these alpha characters and similar numerical figures. MBIs do not contain Social Security Numbers (SSNs) and are unique to each beneficiary.

Unlike Railroad Medicare Health Insurance Claim Numbers (HICNs), which could be identified by their format (1-3 letters followed by 6 or 9 numbers), Railroad Medicare MBIs are indistinguishable from other MBIs. With MBIs you will not be able to tell if a patient is eligible for Railroad Medicare just by looking at the number. The Medicare card of a person with Railroad Medicare will continue to be unique.

The Railroad Retirement Board (RRB) will continue issuing Railroad Medicare cards with the RRB logo in the upper left corner, and ‘Railroad Retirement Board’ at the bottom, as shown here. Railroad Medicare cards will also have a QR code on the front lower right-hand corner of the cards, while Medicare cards will have a QR code on the back of the card. Make sure to ask your patients for their new cards and program your system to identify Railroad Medicare patients based on their cards, if possible.


10 6/2019

Make sure to ask your patients for their new cards and program your system to identify Railroad Medicare patients based on their cards, if possible. If you verify your patient’s eligibility electronically, CMS will return a message on the eligibility transaction response for a Fee-For-Service (FFS) Railroad Medicare MBI inquiry that will read “Railroad Retirement Medicare Beneficiary” in 271 Loop 2110C,Segment MSG.

All Railroad Medicare systems are able to accept MBIs, including our eServices portal and our Interactive Voice Response (IVR) unit. If you need help entering an MBI in the IVR, please use our IVR Conversion Tool at https://www.palmettogba.com/palmetto/ivrt.nsf/Main?OpenForm.

For more information on the new Medicare cards and using the new MBIs, see the following Medicare Learning Network (MLN) resources:

MLN Transition to New Medicare Numbers and Cards Fact Sheet: https://tinyurl.com/MLN-ICN-909365

MLN SE18006 - New Medicare Beneficiary Identifier (MBI) Get It, Use It: https://tinyurl.com/MLN-SE18006


11 6/2019

https://www.palmettogba.com/palmetto/ivrt.nsf/Main?OpenFormhttps://tinyurl.com/MLN-ICN-909365https://tinyurl.com/MLN-SE18006

Typhoon Yutu and Medicare Disaster Related Commonwealth of the Northern Mariana Islands Claims

MLN Matters Number: SE18024 Revised Article Release Date: April 30, 2019 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We revised this article on April 30, 2019, to advise providers and suppliers that the Public Health Emergency and the Section 1135 waiver authority for the Commonwealth of the Northern Mariana Islands expired on April 21, 2019. All other information remains the same.

Provider Types Affected This MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries in the Commonwealth of the Northern Mariana Islands who were affected by Typhoon Yutu.

Provider Information Available Pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of Typhoon Yutu, a major disaster exists in the Commonwealth of the Northern Mariana Islands. On October 25, 2018, Secretary Azar of the Department of Health & Human Services declared that a Public Health Emergency (PHE) exists in the Commonwealth of the Northern Mariana Islands and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to October 24, 2018. On January 17, 2019, Secretary Azar signed a 90-day renewal of the determination that a PHE continues to exist in the Commonwealth of the Northern Mariana Islands due to the effects of Typhoon Yutu, effective January 22, 2019. This renewal extends the authorized waivers and modifications under Section 1135 and Section 1812(f) of the Act in the impacted areas.

On October 26, 2018, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under Section 1812(f) of the Social Security Act for the Commonwealth of the Northern Mariana Islands for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Typhoon Yutu in the Commonwealth of the Northern Mariana Islands in 2018, retroactive to October 24, 2018.

Under Section 1135 or 1812(f) of the Social Security Act, CMS is issuing these blanket waivers consistent with those issued in response to past Public Health Emergency declarations, acknowledging all may not be applicable given the provider types present in the Commonwealth of the Northern Mariana Islands. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency. Providers do not need to apply for an individual waiver if a blanket waiver has been issued. Providers can request an individual Section 1135 waiver, if there is no blanket waiver, by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.


12 6/2019

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf

The most current waiver information is available at https://www.cms.gov/About-CMS/Agency-Information/ Emergency/EPRO/Past-Emergencies/Hurricanes-and-tropical-storms.html. See the Background section of this article for more details.

The Public Health Emergency declaration and Social Security Act waivers including the Section 1135 waiver authority expired on April 21, 2019.

Background Section 1135 and Section 1812(f) Waivers As a result of the aforementioned declaration, CMS has instructed the MACs as follows:

1. Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to itemsand services furnished to Medicare beneficiaries within the Commonwealth of the Northern Mariana Islands fromOctober 24, 2018, for the duration of the emergency. In accordance with CR6451, use of the “DR” conditioncode and the “CR” modifier are mandatory on claims for items and services for which Medicare payment isconditioned on the presence of a “formal waiver” including, but not necessarily limited to, waivers grantedunder either Section 1135 or Section 1812(f) of the Act.

2. The most current information is available athttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.html. Medicare FFS Questions & Answers (Q&As) posted on the waivers and flexibilitiespage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities.html, and also referenced below are applicable for items and services furnished to Medicarebeneficiaries within the Commonwealth of the Northern Mariana Islands. These Q&As are displayed in two files:• One file addresses policies and procedures that are applicable without any Section 1135 or other formal

waiver. These policies are always applicable in any kind of emergency or disaster, including the currentemergency in the Commonwealth of the Northern Mariana Islands.

• Another file addresses policies and procedures that are applicable only with approved Section 1135 waiversor, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved Section1135 blanket waivers and approved individual 1135 waivers requested by providers and are effectiveOctober 24, 2018, for the Commonwealth of the Northern Mariana Islands.

In both cases, the links below will open the most current document. The date included in the document filename will change as new information is added, or existing information is revised. a) Q&As applicable without any Section 1135 or other formal waiver are available athttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf.b) Q&As applicable only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver, areavailable athttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf.

Blanket Waivers Issued by CMS Under the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS is issuing these blanket waivers consistent with those issued in response to past Public Health Emergency declarations, acknowledging all may


13 6/2019

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Past-Emergencies/Hurricanes-and-tropical-storms.htmlhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.htmlhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.htmlhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities.htmlhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf

not be applicable given the provider types present in the Commonwealth of the Northern Mariana Islands. Individual facilities do not need to apply for the following approved blanket waivers:

Skilled Nursing Facilities (SNFs) • Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF

stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Typhoon Yutu in the Commonwealth of the Northern Mariana Islands. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

• 42 CFR 483.20: Waiver provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission (Blanket waiver for all impacted facilities).

Home Health Agencies • 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related

to OASIS Transmission (Blanket waiver for all impacted agencies). • To ensure the correct processing of home health disaster related claims, Medicare Administrative

Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

Critical Access Hospitals This action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours. (Blanket waiver for all impacted hospitals)

Housing Acute Care Patients In Excluded Distinct Part Units CMS has determined it is appropriate to issue a blanket waiver to IPPS hospitals that, as a result of Typhoon Yutu, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to Typhoon Yutu. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the typhoon.)

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital CMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of Typhoon Yutu, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the typhoon. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.


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Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital CMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of Typhoon Yutu, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the typhoon. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster As a result of Typhoon Yutu, CMS has determined it is appropriate to issue a blanket waiver to suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) where DMEPOS are lost, destroyed, irreparably damaged, or otherwise rendered unusable. Under this waiver, the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required for replacement. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS were lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the typhoon.

For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Medicare Advantage Plan or other Medicare Health Plan Beneficiaries CMS reminds suppliers that Medicare beneficiaries enrolled in a Medicare Advantage or other Medicare Health Plans should contact their plan directly to find out how it replaces DMEPOS damaged or lost in an emergency or disaster. Beneficiaries who do not have their plan’s contact information can contact 1-800-MEDICARE (1-800-633-4227) for assistance.

Replacement Prescription Fills Medicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.

Requesting an 1135 Waiver Information for requesting an 1135 waiver, when a blanket waiver hasn’t been approved, can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.

Additional Information If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.


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https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Benefihttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Benefihttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttp://go.cms.gov/MAC-website-list

The Centers for Disease Control and Prevention released ICD-10-CM coding advice (https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdf) to report healthcare encounters in the typhoon aftermath.

Providers may also want to review the CMS Emergency and Preparedness webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.html.

Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html.

Document History Date of Change Description April 30, 2019 We revised the article to advise providers and suppliers that the Public Health

Emergency and the Section 1135 waiver authority for the Commonwealth of the Northern Mariana Islands expired on April 21, 2019. All other information remains the same.

January 23, 2019 This article was revised to advise providers that the PHE declaration and Section 1135 waiver authority for the Commonwealth of the Northern Mariana Islands were renewed, effective January 22, 2019. All other information remains the same.

October 31, 2018 Initial article released.


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https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.htmlhttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certifi

Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary

(QMB) Program MLN Matters Number: MM11230 Related CR Release Date: May 3, 2019 Related CR Transmittal Number: R4290CP Related Change Request (CR) Number: 11230 Effective Date: October 1, 2019 Implementation Date: October 7, 2019 for claims processed on or after this date

Provider Type Affected This MLN Matters Article is for providers and suppliers who serve Qualified Medicare Beneficiaries (QMBs).

What You Need To Know CR 11230 alerts providers of further modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB. Please make sure your billing staffs are aware of these modifications.

Background Through CRs 9911 and 10433, the Centers for Medicare & Medicaid Services (CMS) modified its claims processing systems to identify the QMB status of beneficiaries and exemption from Medicare Parts A and B cost-sharing charges. Articles related to CRs 9911 and 10433 are available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM9911.pdf and https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10433.pdf, respectively.

The QMB program is a State Medicaid benefit that assists low-income Medicare beneficiaries with Medicare premiums and cost sharing, including deductibles, coinsurance, and copays. In 2016, there were 7.5 million individuals (more than one out of eight beneficiaries) enrolled in the QMB program. Some QMBs (22 percent) get state Medicaid assistance with Medicare premiums and cost sharing alone, but most (78 percent) simultaneously have full Medicaid coverage, which may cover care for services that Medicare does not cover.

Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost sharing for covered items and services. (See Sections 1902(n)(3)(B), 1902(n) (3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]). The QMB system updates are part of CMS’ongoing efforts to help providers comply with QMB billing prohibitions. The updates also educate QMBs that they cannot be billed for Medicare deductibles and coinsurance.

As implemented through CRs 9911 and 10433, the Common Working File (CWF) identifies that a beneficiary has active QMB status, which results in Remittance Advice (RA) and Medicare Summary Notice (MSN) messages for QMB claims.


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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10433.pdf

The RA includes two (2) Alert Remittance Advice Remark Codes (RARCs) that identify an individual currently enrolled in QMB and tells providers they may not collect deductible and coinsurance amounts from these beneficiaries. The RAs contain the QMB RARCs only in conjunction with paid claims generating Claim Adjustment Group Code Patient Responsibility (PR) and Claim Adjustment Reason Codes (CARC) 1, 2, and 66, and report Medicare deductible and coinsurance amounts so that coordination of benefits activities may result using copies of RAs if necessary.

The MSN generated for all QMB individuals includes information regarding their QMB status and lack of liability for Medicare cost-sharing amounts for covered Parts A and B items and services However, CMS has recently learned that the claims processing systems do not differentiate between paid and fully denied claims or denied service lines, and initiate the changes whenever an individual is enrolled in QMB. .

CR 11230 includes the following modifications to the claims processing systems to ensure that the MSNs appropriately differentiate between QMB claims that are paid and denied:

MSNs with QMB claims that are paid • If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero,

page one (the summary page), will use MSN Message 62.0 to briefly explain the QMB billing protections (in the “Be Informed!” section).

• Also, on page one, the patient’s total liability amount (in the “Total You May Be billed” field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.

• Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the “Maximum You May Be Billed” field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections.

MSNs with QMB claims that are denied (and also rejected for Fiscal Intermediary Standard System (FISS)) • In the claim detail pages of the MSN, if a detail line is for a QMB and contains an allowed amount of zero,

the MSN: • Will reflect the beneficiary’s total liability amount in the “Maximum You May Be Billed” field and • Include new MSN 11.21 message to inform the beneficiary that even though Medicare has denied the

claim, Medicaid may pay for the care. • Since most QMBs also have full Medicaid coverage, it’s important to convey that their full Medicaid

coverage may cover care that Medicare has denied.

Note: For supplier claims processed by VIPS Medicare System (VMS), if a detail line is flagged as QMB and contains an allowed amount of zero, and the beneficiary has not signed an Advance Beneficiary Notice or is subject to Waiver of Liability which has not been attached, the Medicare Administrative Contractor (MAC) will not print MSN message 11.21.


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Additional Information The official instruction, CR11230, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4290CP.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

For more information, refer to the Qualified Medicare Beneficiary (QMB) Program at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB.html

Document History Date of Change Description May 7, 2019 Initial article released.

New Patient Office or Other Outpatient Visits eCBR Now Available

Comparative Billing Reports (CBRs) are an educational tool you can use to examine your billing patterns and utilization of services in comparison to your peers. eCBRs (electronic CBRs) are located in our free provider portal, eServices, and can be viewed and downloaded online. Our newest eCBR focuses

on providers who have submitted claims for New Patient Office or other Outpatient Visit Evaluation and Management (E/M) Services (CPT codes 99201-99205). If you bill these codes, then this eCBR is for you!

Get your personalized eCBR results on New Patient Visit (E/M) Services (CPT codes 99201-99205) by logging into eServices today at www.PalmettoGBA.com/eServices. An eCBR is available for providers who have at least 10 calims in history for this CPT code family during the time period selected.


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https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4290CP.pdfhttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-O%EF%AC%83ce/QMB.htmlhttp://www.PalmettoGBA.com/eServices

Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes

MLN Matters Number: MM11259 Related CR Release Date: May 10, 2019 Related CR Transmittal Number: R2300OTN Related Change Request (CR) Number: 11259 Effective Date: January 1, 2018 Implementation Date: August 12, 2019

Provider Types Affected This MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11259 advises and provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC). CR 11259 contains advice and educational information for MACs and clinicians reporting the PRC. Make sure your billing staffs are aware of this information.

Background Section 1848(r)(3) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the development of PRC codes to help the attribution of patients and episodes to one or more physicians or applicable practitioners (clinicians) for purposes of cost measurement. Section 1848(r)(4) of the Act requires clinicians, as determined appropriate by the Secretary, to include the applicable PRC codes on claims for items and services furnished on or after January 1, 2018.

During this initial period of implementation, reporting of the PRC on claims is voluntary. In the future, it will be mandatory and tied to cost measures preceded by rulemaking. As of January 1, 2018, Medicare Part B Merit-Based Incentive Payment System (MIPS)-eligible clinicians may now report their patient relationships on Medicare claims using the PRC codes.

Below is the description of the PRC Code Modifiers X1, X2, X3, X4 and X5: • X1 - Continuous/Broad services = For reporting services by clinicians who provide the principal care for

a patient, with no planned endpoint of the relationship • X2- Continuous/Focused services = For reporting services by clinicians whose expertise is needed for the

ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.

• X3 -Episodic/Broad services = For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patients, that is limited to a defined period and circumstance, such as a hospitalization.

• X4 - Episodic/Focused services = For reporting services by specialty focused clinicians who provide time-limited care. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention.


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• X5 - Only as Ordered by Another Clinician = For reporting services by a clinician who furnishes care tothe patient only as ordered by another clinician. This patient relationship category is reported for patientrelationships that may not be adequately captured in the four categories described above.

These categories encompass different scenarios. Information materials on requirements, scenarios and reporting of these code modifiers is available at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/ macra-mips-and-apms/macra-feedback.html.

The Centers for Medicare & Medicaid Services (CMS) has several goals for the voluntary reporting period: • For clinicians to gain familiarity with the categories and experience submitting the codes• To collect data on the use and submission of the codes for analyses to inform the potential future use of

these codes in cost measure attribution methodology in the Quality Payment Program

The codes are currently in a voluntary reporting period. Whether and how the codes are reported on claims will not affect Medicare reimbursement. For now, the modifiers have no impact on beneficiaries.

Reporting of these modifiers will be mandatory in the near future and CMS advises clinicians to participate during the voluntary reporting period to ease transition.

Additional Information The official instruction, CR 11259, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2300OTN.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

Document History Date of Change Description May 16, 2019 Initial article released.


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https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-feedback.htmlhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2300OTN.pdfhttp://go.cms.gov/MAC-website-list

Proper Use of Modifier 59 MLN Matters® Number: SE1418 Revised Related Change Request (CR) #: N/A Article Release Date: May 17, 2019 Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A

Note: We revised this article on May 17, 2019, to reflect that CPT Code 11100 was deleted on January 1, 2019. In Example 1, CPT Code 11100 is replaced with CPT Code 11102. All other information is unchanged.

Provider Types Affected This MLN Matters® Special Edition Article is intended for physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to clarify the proper use of Modifier 59. The article only clarifies existing policy. Make sure that your billing staffs are aware of the proper use of Modifier 59.

Background The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations.

For PTP edits that have a Correct Coding Modifier Indicator (CCMI) of “0,” the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

For PTP edits that have a CCMI of “1,” the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI-associated modifiers. (Refer to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, for general information about the NCCI program, PTP edits, CCMIs, and NCCI-associated modifiers. This manual is available in the download section at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html)

One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

The CPT Manual defines modifier 59 as follows: “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


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http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

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 performed on the same date, see modifier 25.”

Modifier 59 and other NCCI-associated modifiers should 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-associated modifier that is used. 1. Modifier 59 is used appropriately for different anatomic sites during the same encounter only

when procedures which are not ordinarily performed or encountered on the same day are per-formed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers –that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI. (See examples 1, 2, and 3.) From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. Modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. For example: • Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the

distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site. (See example 4.)

• Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site. (See example 5.)

• Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site. (See example 6.)

2. Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day. Another common use of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers – i.e., 24, 25, 27, 57, 58, 78, 79, or 91. (See example 7) As noted in the CPT definition, modifier 59 should only be used if no other modifier more appropriately describes the relationship of the two procedure codes.

3. Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different. One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59


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allowing its use to describe a “different procedure or surgery.” The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be “separate and distinct.” The provider should not use modifier 59 for such an edit based on the two codes being “different procedures.” (See example 8.) However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures on that date of service. Additionally, there may be limited circumstances sometimes identified in the National Correct Coding Initiative Policy Manual for Medicare Services (available in the downloads section at https://www.cms.gov/Medicare/Coding/ NationalCorrectCodInitEd/index.html) when the two codes of an edit pair may be reported together with modifier 59 when performed at the same patient encounter or at the same anatomic site.

4. Other specific appropriate uses of modifier 59There are three other limited situations in which two services may be reported as separate and distinctbecause they are separated in time and describe non-overlapping services even though they may occurduring the same encounter, i.e.:

A. Modifier 59 is used appropriately for two services described by timed codes provided during thesame encounter only when they are performed sequentially. There is an appropriate use for modifier59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 min-utes, per hour). If two timed services are provided in time periods that are separate and distinct and notinterspersed with each other (i.e., one service is completed before the subsequent service begins), modi-fier 59 may be used to identify the services. (See example 9.)

B. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic proce-dure only when the diagnostic procedure is the basis for performing the therapeutic procedure.When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure andis the basis on which the decision to perform the surgical procedure is made, that diagnostic test may beconsidered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic proce-dure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearlyprovides the information needed to decide whether to proceed with the therapeutic procedure; and (c) itdoes not constitute a service that would have otherwise been required during the therapeutic interven-tion. (See example 10.) If the diagnostic procedure is an inherent component of the surgical procedure, itshould not be reported separately.

C. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a com-pleted therapeutic procedure only when the diagnostic procedure is not a common, expected, ornecessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgicalprocedure or non-surgical therapeutic procedure, that diagnostic procedure maybe considered to be aseparate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedureand is not interspersed with or otherwise commingled with services that are only required for the ther-apeutic intervention, and (b) it does not constitute a service that would have otherwise been requiredduring the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent componentor otherwise included (or not separately payable) post-procedure service of the surgical procedure ornon-surgical therapeutic procedure, it should not be reported separately.


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Use of Modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Modifiers XE, XS, XP, and XU are effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more specific modifier is appropriate.)

Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, providers may begin using them for claims with dates of service on or after January 1, 2015. The modifiers are defined as follows: • XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter”

This modifier should only be used to describe separate encounters on the same date of service. • XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/

structure” • XP – “Separate Practitioner, Aservice that is distinct because it was performed by a different practitioner” • XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not

overlap usual components of the main service”

Examples of Modifier 59 Usage Following are some examples developed to help guide physicians and providers on the proper use of Modifier 59 (Please remember that Medicare policy is that Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day 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.):

Example 1: Column 1 Code / Column 2 Code - 17000/11102 • CPT Code 17000 – Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical

curettement), premalignant lesions (eg, actinic keratoses); first lesion • CPT Code - 11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion

Modifier 59 may be reported with code 11102 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day 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.

Example 2: Column 1 Code/Column 2 Code 47370/76942 • CPT Code 47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency


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• CPT Code 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT code 76942 should not be reported and Modifier 59 should not be used if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure. Code 76942 may be reported with modifier 59 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Example 3: Column 1 Code/Column 2 Code 93453/76000 • CPT Code 93453 – Combined right and left heart catheterization including intraprocedural injections(s)

for left ventriculography, imaging supervision and interpretation, when performed • CPT Code 76000 – Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or

71034 (eg, cardiac fluoroscopy)

CPT code 76000 should not be reported and Modifier 59 should not be used for fluoroscopy that is used in conjunction with a cardiac catheterization procedure. Modifier 59 may be reported with code 76000 if the fluoroscopy is performed for a procedure unrelated to the cardiac catheterization procedure.

Example 4: Column 1 Code / Column 2 Code - 11055/11720 • CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion • CPT Code 11720 – Debridement of nail(s) by any method(s); one to five

CPT codes 11720 and 11055 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifier 59 should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifier 59 may be reported with code 11720 if one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

Example 5: Column 1 Code / Column 2 code - 67210/67220 • CPT Code 67210 – Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions;

photocoagulation • CPT Code 67220 – Destruction of localized lesion of choroid (eg, choroidal neovascularization);

photocoagulation (eg, laser), 1 or more sessions

CPT code 67220 should not be reported and Modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ.

Example 6: Column 1 Code / Column 2 Code - 29827/29820 • CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair • CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

CPT code 29820 should not be reported and Modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not Modifier 59.


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Example 7: Column 1 Code / Column 2 Code - 93015/93040 • CPT Code 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise,

continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report

• CPT Code 93040 – Rhythm ECG, one to three leads; with interpretation and report

Modifier 59 may be reported if the rhythm ECG is performed at a different encounter than the cardiovascular stress test. If a rhythm ECG is performed during the cardiovascular stress test encounter, CPT code 93040 should not be reported and Modifier 59 should not be used. Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.

Example 8: Column 1 Code/Column 2 code - 34833/34820 • CPT code 34833 - Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis

or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

• CPT code 34820 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

CPT code 34833 is followed by a CPT Manual instruction that states: “(Do not report 34833 in conjunction with 33364, 33953, 33954, 33959, 33962, 33969, 33984, 34820 when performed on the same side).” Although the CPT code descriptors for 34833 and 34820 describe different procedures, they should not be reported together for the same side. Modifier 59 should not be appended to either code to report the two procedures for the same side of the body. If the two procedures were performed on different sides of the body, they may be reported with modifiers LT and RT as appropriate. However, modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

Example 9: Column 1 Code / Column 2 Code - 97140/97530 • CPT Code 97140 – Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage,

manual traction), one or more regions, each 15 minutes • CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of

dynamic activities to improve functional performance), each 15 minutes

Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block. Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.

Example 10: Column 1 Code / Column 2 Code - 37220/75710 • CPT Code 37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial

vessel; with transluminal angioplasty • CPT Code 75710 – Angiography, extremity, unilateral, radiological supervision and interpretation.


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Modifier 59 may be reported with CPT code 75710 if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery. Modifier 59 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.

Additional Information The CMS webpage on the National Correct Coding Initiative Edits is available at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.

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