CMS clarifies guidance for resolving PTP edits and MUEs, reporting modifiers -59 and -91

CMS released Transmittal 4188 on December 28, adding instructions to Chapter 23 of the Medicare Claims Processing Manual for the accurate interpretation of claim edits and assignment of modifiers -59 (distinct procedural service) and -91 (repeat clinical diagnostic laboratory test) on Medicare Part B claims.

The agency added new language to the manual, clarifying the purpose of procedure-to-procedure (PTP) edits and providing guidance for Medicare Administration Contractors (MAC) on appealing claims with PTP edits assigned Correct Coding Modifier Indicators of 0 or 1.

CMS also added general guidance for the interpretation of medically unlikely edits (MUE) and instructions for MACs on appealing claims with MUEs assigned adjudication indicators of 1, 2, or 3.

In addition, CMS added detailed information on the accurate reporting of modifiers -59 and -91 on Part B claims. According to CMS, modifier -59 is mainly used to identify:

• Separate anatomic sites when during a single encounter, procedures are performed on different organs, different anatomic regions, or on distinct, non-contiguous lesions in different anatomic regions of the same organ
• Procedures performed in different encounters on the same day

However, there are a few uncommon situations, described in detail in the updated manual, for which it would be appropriate to report modifier -59. Additional information and examples for the proper use of modifier -59 can be found here.

According to CMS, modifier -91 may be appended to laboratory services to indicate a repeat test or procedure on the same day, when appropriate. Notably, this modifier can’t be used to report repeat laboratory testing due to errors, quality control issues, or confirmation of results.

Editor's note: This article originally appeared on Revenue Cycle Advisor.