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Modifier 59 and the Subset Modifiers XE, XP, XS, XU – Specific Modifiers for Distinct Procedural Services

Continued Use of Modifier 59 after 1/1/2015

CMS implemented CR8863 on 1/5/2015, effective 1/1/2015 to clarify the continued use of modifier 59 after 1/1/2015. This CR established four new HCPCS modifiers (XE, XP, XS, XU) to define specific subsets of the 59 modifier, a modifier used to define a “Distinct Procedural Service.” These modifiers are collectively referred to as X (EPSU) modifiers. Please note that providers may continue to use the 59 modifier after 1/1/ 2015, in any instance in which it was correctly used prior to 1/1/2015. The initial CR establishing the modifiers was designed to inform system developers that healthcare systems would need to accommodate the new modifiers. Additional guidance and education as to the appropriate use of the new X (EPSU) modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled fashion. That guidance will include additional descriptive information about the new modifiers. CMS will identify situations in which a specific X (EPSU) modifier will be required and will publish specific guidance before implementing edits or audits. CR8863 states that providers who wish to use the new modifiers may use them in accordance with their published definitions, and the X modifiers will function within CMS systems in the same manner as the 59 modifier, bypassing PTP edits with a modifier indicator of “1,” for example. A modifier indicator of “1” indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances.

Read more in SE1503: Continued Use of Modifier 59 after January 1, 2015.

Modifier 59

Modifier 59 is defined as a Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.

Appropriate Usage

  • Documentation indicates two separate procedures performed on the same day by the same physician
  • Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)
  • Use modifier 59 with the secondary, additional or lesser procedure of combinations listed in NCCI edits.
  • Use modifier 59 when there is no other appropriate modifier.
  • Use modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service.

Read more in SE1418: Proper Use of Modifier 59

Modifier XE

Modifier XE is defined as a Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Modifier XP

Modifier XP is defined as a Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

Modifier XS

Modifier XS is defined as a Separate Structure, A Service That Is Distinct Because It Was Performed on A Separate Organ/Structure

Modifier XU

Modifier XU is defined as a Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

Appropriate Usage of the X Modifiers

  • CMS has not issued specific instructions on the use of the new X modifiers, therefore, providers may continue to use modifier 59 in all situations in which it was previously appropriate.
  • When coding pairs are part of the NCCI procedure to procedure edits, CMS will issue detailed instructions before edits require an X modifier in place of modifier 59.
  • If used, use X modifiers with the Column 2 procedure code in the NCCI files.
  • If used, use X modifiers only in accordance with their definition and in accordance with NCCI Manual instructions regarding the appropriate instances in which specific NCCI edits may be bypassed.

Inappropriate Usage of X Modifiers

  • Providers are encouraged to use modifier 59 in the absence of specific CMS instructions in order to avoid the inappropriate use of the new X modifiers.
  • X modifiers may not be used in instances where the bypass of the edit is not in accordance with CMS regulation, Internet Only Manual or NCCI Manual instruction.
  • X modifiers should not be submitted with modifier 59 for the same service.

Additional Information and Related Content

  • NCCI listings can be found on the CMS National Correct Coding website.
  • Medicare considers two physicians in the same group with the same specialty performing services on the same day the same physician.
  • Providers should evaluate other modifiers such as the RT/LT identifying right and left, F1 - F0 to identify fingers, T1-T0 to identify toes and E1-E4 to identify eyelids. Evaluate additional modifiers to determine appropriate usage.
  • Modifier 59 is a valid modifier and if the situation meets the distinct procedural services as defined in the NCCI Manual, then modifier can be used.
Modifier 59 and the Subset Modifiers XE, XP, XS, XU - Specific Modifiers for Distinct Procedural Services
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