MA PPO

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


Policy

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.

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

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


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

12/16/2019
12/16/2019
MA03.005
Claim Payment Policy Bulletin
Medicare Advantage
Yes