The Proper Use of Modifiers 59 & –X{EPSU}

The Medicare National Correct Coding Initiative (NCCI) provides PTP (Procedure-to-Procedure) edits that stipulate when providers aren’t allowed to report certain HCPCS or CPT codes together. Here are the key points: 

• In the case of NCCI PTP-associated edits with a correct coding modifier indicator (CCMI) of “0”, the codes shouldn’t be reported together by the same provider for the same beneficiary on the same date of service. When the codes are reported together on the same date of service, the code on Column One would be eligible for payment, but Medicare would reject the Column Two code. 
• In the case of NCCI PTP-associated edits with a CCMI of “1,” the codes may be reported together using specific NCCI PTP-associated modifiers but only in stipulated circumstances. 

NCCI PTP-associated edits help to prevent payment for codes that report overlapping services apart from a situation where the services are “separate and distinct.” Modifier 59 is one useful NCCI PTP-associated modifier, but providers usually misuse it.