Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Modifiers XE, XS, XP, XU, and 59

Notification Issue Date:

This 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.

Title:

Modifiers XE, XS, XP, XU, and 59

Policy #:

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 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.

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. 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 November 18, 2021.

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. November 18, 2021.

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 November 18, 2021.

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 November 18, 2021.

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

MPMiscCodesNarrativesPub
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 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

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

1/31/2022

Version Issued Date: