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 policy applies to professional and outpatient facility claims.
Modifiers XE, XS, XP, XU or 59 when used to indicate that two or more procedures or services reported on the same day are distinct or separate, are eligible for reimbursement consideration by the Company, when any of the following circumstances are met:
Modifiers XE, XS, XP, and XU are used in the following circumstances:
- 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, XU, and 59 are not eligible for reimbursement consideration.
Modifier 59 should only be reported when a procedure or service cannot be accurately reported with modifier XE, XS, XP, or XU, which should be an infrequent occurrence.
It is not appropriate to append modifiers XE, XS, XP, XU and/or 59 in the following circumstances:
- To an evaluation and management (E & M) procedure code.
- As a replacement for modifiers 24, 25, 27, 57, 58, 78, or 79, or 91.
- When another more specific anatomic modifier better describes the service (e.g. RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI).
- With Modifier 51 on the same procedure code.
- A single procedure code appended with more than one of the XE, XS, XP, XU, or 59 modifiers.
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.
Claims submitted with Modifiers XE, XS, XP, XU or 59 are subject to pre- and post-payment review and potential denials or retractions for inappropriate use. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
BILLING REQUIREMENTS
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
