Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifiers XE, XS, XP, XU, and 59
Policy #:MA03.005b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

MODIFIERS XE, XS, XP, AND XU (components of modifier 59)

Modifiers XE, XS, XP, XU should be used in the following situations:
  • Modifier XE for a service that is distinct because it occurred during a separate encounter
  • Modifier XS for a service that is distinct because it was performed on a separate organ/structure
  • Modifier XP for a service that is distinct because it was performed by a different practitioner
  • Modifier XU for a service that is distinct because it does not overlap usual components of the main service
Single-line claims submitted by the same provider with Modifier XS or XU are not eligible for reimbursement consideration.

MODIFIER 59

Modifier 59 should only be reported when a service cannot be accurately reported with modifier XE, XS, XP, or XU, which should be an infrequent occurrence.

Single-line claims submitted by the same provider with Modifier 59 are not eligible for reimbursement consideration.

INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIERS XE, XS, XP, XU, OR 59

The following circumstances are inappropriate for appending modifiers XE, XS, XP, XU, or 59:
  • Modifier XE, XS, XP, XU, or 59 should not be appended to an evaluation and management (E & M) procedure code.
  • Modifier XE, XS, XP, XU, or 59 should not be reported as a replacement for modifiers 24, 25, 78, or 79.
  • Modifier XE, XS, XP, XU, or 59 should not be reported when another modifier better describes the service.
  • Modifier XE, XS, XP, XU, or 59 should not be reported with Modifier 51 on the same procedure code.
  • Modifier 59 should not be reported when one of the more descriptive modifiers of XE, XS, XP, or XU, should be reported.
  • Modifier 59 should not be reported on a single line claim.
  • A single procedure code cannot be reported with more than one of the following modifiers: XE, XS, XP, XU, or 59.

Claims submitted with Modifiers XE, XS, XP, XU or 59 are subject to post-payment review and potential retractions for inappropriate use.

Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

REQUIRED DOCUMENTATION

The member's medical record must contain the supporting medical necessity documentation describing the circumstances precipitating the performance of the subsequent procedure or service. The member's medical records must be made available to the Company upon request. These medical records may include, but are not limited to, the following: records from the physician's office, hospital, nursing home, home health agency, other health care professionals, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider.
Policy Guidelines


Description

Under certain circumstances, it may be necessary to indicate that a procedure or service is separate, distinct, or independent from other services that are performed on the same day by the same provider. Modifiers XE, XS, XP, XU, and 59 represent these circumstances:

  • XE– “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  • XS– “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
  • XP– “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
  • XU– “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”
  • 59 – “Distinct Procedural Service”

The addition of Modifier XE, XS, XP, or XU to a procedure code indicates that the procedure represents any of the following:
  • a different session
  • a different procedure or surgery
  • a different site or organ system
  • a separate incision/excision
  • a separate lesion
  • a separate injury (or area of injury in extensive injuries)

References

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 23: Fee schedule administration and coding requirements. [CMS Web site]. Revised 05/03/2019. Available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed October 8, 2019.

Centers for Medicare and Medicaid Services (CMS). MLN Matters Number: MM8863. 01/01/2015. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf. Accessed October 8, 2019.

Novitas Solutions, Inc. Modifier 59 and New Modifiers XE, XS, XP, XU. 07/09/2019. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00087124. Accessed October 8, 2019.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifier:


XE Separate encounter, A service that is distinct because it occurred during a separate encounter

XS Separate Structure, A service that is distinct because it was performed on a separate organ/structure

XP Separate Practitioner, A service that is distinct because it was performed by a different practitioner

XU Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service

59 Distinct Procedural Service


Coding and Billing Requirements






Policy History

Revision from MA03.005b:
12/16/2019This version of the policy becomes effective 12/16/2019. This policy update reaffirms the Company's continuing position on reporting of modifiers XE, XS, XP, XU, and 59.

Revision from MA03.005a:
11/21/2018This policy has been reissued in accordance with the Company's annual review process.
07/01/2015Revised policy number MA03.005a was issued as a result of an annual policy review. The References were updated accordingly. The policy was updated to be consistent with current template wording and format. The adoptable source for this policy is CMS.

The below modifiers were added to the policy:
  • Modifier XE for a service that is distinct because it occurred during a separate encounter
  • Modifier XS for a service that is distinct because it was performed on a separate organ/structure
  • Modifier XP for a service that is distinct because it was performed by a different practitioner
  • Modifier XU the use of a service that is distinct because it does not overlap usual components of the main service.

Policy Guidelines have been removed as it was determined it is no longer needed.

Revision from MA03.005:
01/01/2015This is a new policy.





Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A