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.

Title:

Modifiers XE, XP, XS, XU, and 59

Policy #:

MA03.005d

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.

In certain circumstances, it may be necessary to identify that a service is distinct or separate from another service performed on the same date. In such cases, the Company requires submission of the most appropriate and specific modifier to accurately reflect the distinct nature of the service provided.

ELIGIBLE FOR REIMBURSEMENT

Services appropriately reported with Modifiers XE, XP, XS, XU, or 59, to indicate that a service is distinct or separate from another service performed on the same date, are eligible for reimbursement consideration by the Company in the following circumstances:

When Modifiers XE, XP, XS, or XU are reported with any service or procedure code to indicate any of the following:

Modifier XE for a service that is distinct because it occurred during a separate encounter
Modifier XP for a service that is distinct because it was performed by a different practitioner
Modifier XS for a service that is distinct because it was performed on a separate organ/structure
Modifier XU for a service that is distinct because it does not overlap usual components of the main service

When Modifier 59 is reported with a time-based service or time-based procedure code and Modifiers XE, XP, XS, or XU, do not better desribe the distinct nature of the service.

NOT ELIGIBLE FOR REIMBURSEMENT

Unless the service is time-based, services or procedure codes reported with Modifier 59 are not eligible for reimbursement consideration by the Company. In this instance, the Company requires submission of Modifiers XE, XP, XS, or XU to reflect the distinct nature of the service provided.

Services or procedure codes are not eligible for reimbursement consideration by the Company when reported with Modifiers XE, XP, XS, XU or 59 in any of the following circumstances:

With an evaluation and management (E/M) procedure code
When a more specific modifier better describes the distinct nature of the service (e.g. RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI)
As a replacement for Modifiers 24, 25, 27, 57, 58, 78, or 79, or 91
When Modifier 51 is reported for the same procedure code
A single procedure code is reported with more than one XE, XP, XS, XU, or 59 modifiers
A single line claim is submitted with modifiers XE, XP, XS, XU, or 59

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, XP, XS, 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 service is separate, distinct, or independent from other services that are performed on the same day. Modifiers XE, XP, XS, 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.
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 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”

Appending Modifier XE, XP, XS, or XU to a procedure code indicates that the service 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)

Modifier 59 is considered a modifier of last resort and should be reported only when no other more descriptive or specific modifier is available to appropriately identify the distinct nature of the service. For the purposes of this policy, Modifier 59 should only be reported for time-based services or time-based procedure codes.

Time-based services are reported using procedure codes that include time increments explicitly identified in the CPT/HCPCS code descriptor and are used as a controlling factor for code selection or unit reporting. The reported service must meet the documented time requirements as defined by applicable CPT/HCPCS coding guidelines.

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 June 17, 2026.

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. Accessed June 17, 2026.

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 June 17, 2026.

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 June 17, 2026.

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 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

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA03.005d:

10/01/2026

This version of the policy will become effective 10/01/2026.

The Company’s reimbursement position has been revised to consider services reported with Modifier 59 that are not time-based and not eligible for reimbursement consideration. Time-based services reported with Modifier 59 when more specific modifiers are appropriate are not eligible for reimbursement consideration. More specific modifiers XE, XP, XS, XU appropriately reported to indicate distinct or separate services performed on the same date remain eligible for reimbursement consideration by the Company.

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.
01/31/2022	This 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

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

01/31/2022

This 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:

12/16/2019

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.

Revisions From MA03.005a:

11/21/2018

This policy has been reissued in accordance with the Company's annual review process.

07/01/2015

Revised 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:

01/01/2015

This is a new policy.

Version Effective Date:

10/1/2026

Version Issued Date: