Modifier 59 use in Rural Communities
The February 2024 Medicare Learning Network (MLN) from the Centers for Medicare and Medicaid Services (CMS) has updated the definitions of modifiers 59, XE, XP, XS, & XU. These updates include when a single Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) visit constitutes more than 1 RHC or FQHC practitioner encounter on the same day or multiple encounters with the same RHC or FQHC practitioner on the same day. It is payable as 1 visit, and this policy applies even in the following circumstances:
- Length or complexity of the visit
- Number or type of practitioners seen
- Second visit is scheduled or unscheduled
- First visit is related or unrelated to the subsequent visit
An exception to this policy occurs when the patient, after the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day.
The two exceptions are:
- The patient has a medical visit and a mental health visit on the same day (2 billable visits)
- For RHCs only, the patient has an initial preventive physical exam (IPPE) and a separate medical, mental health visit, or both on the same day as the IPPE.
Layman terms: The first option happens when a single patient sees the same Practitioner at both a Rural Health Clinic or Federally Qualified Health Center for a visit that turns into multiple visits on the same day in both the RHC or FQHC or multiple encounters with the same RHC or FQHC practitioner on the same day. Despite the length or complexity of medical decision-making, the first visit is related or unrelated to the second visit, if the second visit is scheduled or unscheduled, and the number or type of providers seen on the same day. Only one visit is billable on the date of service.
An additional E/M visit can be billed on the same day as a patient is seen on the same day by the same RHC or FQHC practitioner. Under the following conditions, when the patient, after the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day. The FQHC would use modifier 59 on the claim, and the RHC would use modifier 59 or 25 to identify whether the patient’s treatment qualifies for two billable visits.
Applies to Provider Types: Physicians, Physician Assistant, Certified Nurse Practitioner
Applicable Year: 2024
Location: Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC)
Example 1: Patient is seen this morning by Dr. A for a headache in his Rural Health Clinic office and a few hours later saw Dr. A in the office at his Federally Qualified Health Center. Both visits have low medical decision-making. Due to the second visit not providing a new diagnosis, only one visit is billed for today’s visits.
Example 2: A patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the RHC or FQHC. In this situation, the FQHC would use modifier 59 on the claim, and the RHC would use modifier 59 or 25 to show that the treatment qualifies for 2 billable visits.
Example 3: The patient has a medical visit and a mental health visit on the same day (2 billable visits)
Example 4: Patient B is being seen in an RHC only, the patient has an initial preventive physical exam (IPPE) and a separate medical, mental health visit, or both on the same day as the IPPE (2 or 3 billable visits) with modifier 25 or 59.
