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MA PPO Host - Claim Payment Policy Bulletin

Modifiers XE, XS, XP, XU, and 59
MA03.005c

Policy

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 agen​cy, 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.

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. 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 September 09, 2024.

Centers for Medicare and Medicaid Services (CMS). MLN Matters Number: MM8863. 01/01/2015. Available at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/MM8863.pdf. September 09, 2024.

Centers for Medicare and Medicaid Services (CMS). MLN Fact Sheet. Proper Use of Modifiers 59 & -X(EPSU). 3/2021. Available at: https://www.cms.gov/files/document/proper-use-modifiers-59-xepsu.pdf. Accessed September 09, 2024.

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 September 09, 2024​.​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A

Modifiers

59 Distinct Procedural Service

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

XP Separate practitioner, a service that is distinct because it was performed by a Separate encounter, a service that is distinct because it occurred during a separate encounter different practitioner

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

XU Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service​

Policy History

Revisions From MA03.005c:
09/18/2024​This policy has been reissued in accordance with the Company's annual review process.​​​​
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​​
01/31/2022This version of the policy will become effective 01/31/2022. The policy was updated to clarify coverage and appropriate use of Modifier 59.

The following has been added to the policy:
​​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:

​The following has been added to the Required Documentation section of this policy for claims reported with Modifier 59:
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​​

Revisions 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.

Revisions 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.

Revisions From MA03.005:
01/01/2015This is a new policy.
01/31/2022
01/31/2022
09/18/2024
MA03.005
Claim Payment Policy Bulletin
Medicare Advantage
No
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