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.
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.
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
Policy: 08.00.66m:Bevacizumab (Avastin®) and Related Biosimilars
Policy: 10.02.02i:Chiropractic Spinal and Extraspinal Manipulation Therapy
Policy: 10.03.01j:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 10.03.01k:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 11.08.23j:Mohs' Micrographic Surgery