Modifier 59: Stop Misuse and Audits


Consistent misuse and abuse of modifier 59 has put it on the Office of the Inspector General’s active radar. Meaning they are just waiting for you to slip up. To make matters worse, modifier 59 sub-modifiers (XE, XS, XP, XU) and varying carrier guidelines, make it even more difficult to get it right. In fact, CMS Transmittal 1422 projected error rates for modifier 59 at $320 million in physician claims.

Considering the size of these projected overpayments, you can rest assured that CMS is sitting up and paying close attention and will be working hard to recoup this reimbursement.

So, what does this mean to you? If you’re found to be using modifier 59 erroneously, the reimbursements you received for those services will be taken back by CMS. And if that leads to a full scale audit of your modifier 59 claims, you could also have to pay $10,000 for EACH time it was submitted on a claim.

Your only defense is to take action. You need to get a firm handle on complying with modifier 59 guidelines – including the new sub-modifiers – XE, XS, XP and XU, and national coding expert, Dawn Cloud, CPC, CMSCS, CHCI, can show you how during her 60-minute online training session.

Here are just a few of the practical, step-by-step strategies you’ll receive by viewing for Dawn’s 60-minute online training session:

•  Never mix up modifiers 59, 51 (Multiple Procedures) and
50 (Bilateral Procedures)
•  Audit proof documentation phrases to justify your use of the
new modifier 59 sub-modifiers
•  Don’t allow E/M services and modifier 25 to confuse correct
modifier 59 usage
•  Decipher Correct Coding Edits (CCI) 0, 1 and 9 as a key to
unlock correct modifier application
•  Maximize reimbursement with correct usage strategies for new
    modifiers –XE, XS, XP, XU
•  Correctly apply modifiers in the right order and to the right
 to get paid accurately
• And so much more

IMPORTANT: You may think that if you don’t bill Medicare you don’t have to worry about this, but think again. Although this change is for Medicare – private insurers are quickly following suit.

And remember, ignorance is not an acceptable defense against fraud violations. If you are targeted for an audit and found to be applying modifier 59 and its sub-modifiers incorrectly, or if your documentation doesn’t back up their use, you could really regret it.

Don’t risk it, register for this must-attend training session today and finally understand these complex and dangerous modifiers.




Meet Your Expert

Dawn R. Cloud
CPC, CMSCS, CHCI, CPDMDean, Professional Association of Healthcare Coding Specialists (PAHCS) Academy

Dawn has 25 years’ experience in the Medical Industry. She also provides consulting services to physicians to maximize and manage their revenue through proper documentation, coding and billing.

She is a Certified Professional Coder through AAPC since 1999, and holds a multi-specialty credential, a Certified Instructor credential, and an Office Manager credential through PAHCS since 2003.

She is the Co-founder of the East Valley Chapter for AAPC in AZ. She has been published in PAHCS newsletters and Family Practice Coding Advisor. She currently works teaching Coding Compliance and Consulting for Specialists. Her specialties cover the gamut of medicine and surgery.


Wonderful clarification with mod usage.
Lisa Stives
Profee Coder, Re|Solution
The speaker was very clear and easy to understand.
Jane Randall
Billing Manager, Lotus Dermatology
The exact explanations were quite useful. Especially the X modifiers, It has been so confusing. I was told to use them then nothing was getting paid and my manager was distraught till we went back to not using them and using 59 again.
Dian M Schmidt
Billing and Coder, Sinai Hospital of Baltimore
It was informative. I did learn a few new things.
Diana Kraus
Physician Accounts Specialist, Hopedale Medical Complex
It was short but to the point, very informative.
Jennifer Reyez
Billing manager, Western Healthcare Alliance