Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifiers XE, XS, XP, XU, 59

Policy #:03.00.08d

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

The following circumstances are appropriate for appending modifier XE, XS, XP, XU, or 59:
  • 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.
  • Modifier 59 should only be reported when it is the most accurate modifier that is available to describe the circumstances of the procedure or service and Modifier XE, XS, XP, or XU do not meet the criteria.

The following circumstances are inappropriate for appending modifier XE, XS, XP, XU, or 59:
  • To an evaluation and management (E&M) procedure code
  • As a replacement for Modifiers 24, 25, 78, or 79
  • When another modifier best describes the service
  • When reported with Modifier 51 on the same procedure code
  • Reporting modifier 59 when the more descriptive modifiers XE, XS, XP, or XU should have been reported

A single procedure code cannot be reported with more than one of the following modifiers: XE, XS, XP, XU, or 59.

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, records from the physician's office, hospital, nursing home, home health agency, other health care professionals, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. Claims submitted with Modifiers XE, XS, XP, XU or 59 are subject to post-payment clinical review and potential retractions for inappropriate use.
Guidelines



Description

Under certain circumstances it may be necessary to indicate that a procedure or service is separate, distinct, or independent from other non-evaluation and management (E&M) services performed on the same day by the same individual. These circumstances may be reported by appending Modifiers XE, XS, XP, XU, or 59 to the applicable procedure code.
  • Modifier XE: Separate Encounter
  • Modifier XS: Separate Structure
  • Modifier XP: Separate Practitioner
  • Modifier XU: Unusual Non-Overlapping Service
  • Modifier 59: Distinct Procedural Service

The addition of Modifier XE, XS, XP, XU, or 59 to a procedure code indicates that the procedure represents a different:
  • Session
  • Procedure or surgery
  • Anatomic site or organ system
  • Lesion, through a separate performed incision/excision or for a separate injury or area of extensive injuries
  • Procedure not ordinarily encountered or performed on the same day by the same individual

References


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

Centers for Medicare and Medicaid Services (CMS). MLN Matters Number: MM8863: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf




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:


Modifier XE: Separate Encounter
Modifier XS: Separate Structure
Modifier XP: Separate Practitioner
Modifier XU: Unusual Non-Overlapping Service
Modifier 59: Distinct Procedural Service


Coding and Billing Requirements


Cross References


Policy History

REVISIONS FROM 03.00.08d:
11/21/2018This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 07/01/2015
Version Issued Date: 07/01/2015
Version Reissued Date: 11/26/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.