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Policy No: 105

Originally Created: 11/01/2008

Section: Modifiers

Last Reviewed: 07/01/2019

Last Revised: 07/01/2018

Approved: 07/18/2019

Effective: 08/01/2019

This policy applies to ASCs, physicans and other qualified health care professionals, hospitals and other facilities.

Definitions

Current Procedural Terminology (CPT®) Modifier 59

A two-position numeric code that indicates a procedure or service is distinct or independent from other non-Evaluation and Management (E&M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E&M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must be present to support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

Healthcare Common Procedure Code System (HCPCS) Modifier XE

A two-position alpha code that indicates a procedure or service is distinct because it occurred during a separate encounter. Documentation must be present to support a procedure or service that occurred during a separate encounter.

HCPCS Modifier XP

A two-position alpha code that indicates a procedure or service is distinct because it was performed by a different practitioner. Documentation must be present to support the procedure or service was performed by a different practitioner on the same day as another service.

HCPCS Modifier XS

A two-position alpha code that indicates a procedure or service is distinct because it was performed by on a separate organ/structure. Documentation must be present to support a separate site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual.

HCPCS Modifier XU

A two-position alpha code that indicates a procedure or service is distinct because it does not overlap usual components of the main service. Documentation must be present to support a distinct procedure or surgery not ordinarily encountered or performed as part of a main service.

Policy statement

Codes submitted with modifier 59, XE, XP, XS, or XU attached are considered appropriate coding to the extent they comply with the above definitions.  Adding a bypass modifier to most or all codes on the claim where the service is not distinct or independent or without support in patient notes is considered inappropriate use of the modifiers.

Documentation to support use of modifiers 59, XE, XP, XS or XU must be present in patient's medical record.

CPT codes submitted with modifier 59, XE, XP, XS or XU attached are not reimbursable when considered a bundled component of a more comprehensive code or two codes that should not be reported together based on National Correct Coding Initiative (NCCI) edits, NCCI coding guidelines, or our Correct Code Editor (CCE) edits.

Modifier 59 should not be used when a more descriptive modifier is available. Modifiers XE, XP, XS and XU are more selective versions of modifier 59 but must not be used on the same line as modifier 59.

Examples of proper use of modifiers 59, XE, XP, XS or XU:

  • Modifier XE - A patient has a cardiovascular stress test in the morning and a rhythm ECG in the afternoon. Modifier XE should be used on the rhythm ECG CPT code since the cardiovascular stress test was performed at a different encounter than the rhythm ECG.
  • Modifier XP - A patient has a cardiovascular stress test and is then referred to a different provider to do a rhythm ECG.  Modifier XP must be appended to the rhythm ECG CPT code to indicate it was performed by a different provider than the cardiovascular stress test.
  • Modifier XS - A provider performs a destruction a of a benign or premalignant lesions on patient's cheek and performs a biopsy of the skin, single lesion on the patient's chest. Modifier XS must be appended to the biopsy CPT code to indicate that it was performed on a different anatomic site than the destruction.

Modifier 59 - If your circumstance does not fit into one of the examples above, modifier 59 may be appropriate for use.

Examples of Improper use of modifiers 59, XE, XP, XS or XU:

  • Procedures in the same ipsilateral joint (including different compartments) performed by open, scope, or combined open/scope technique, including added port or incisional sites. [Per our reimbursement policy the edits are applicable per entire joint and not per compartment within a joint].
  • Procedures in the same anatomical site (e.g. digit, breast, etc), even with incision lengthening or contiguous incision.
  • CPT identified "separate" procedures performed in the same session, same anatomic site, or orifice.
  • Scope procedure converted to open procedure.
  • Open procedure converted to scope procedure when all services could have been provided within the open incision.
  • Incisional repairs are part of the global surgical package, including deliveries.
  • Contiguous structures in the same anatomic site, organ system, or joint.

References

American Medical Association. Appendix A – Modifiers. Current Procedural Terminology (CPT) Chicago: AMA Press 2013.

Centers for Medicare & Medicaid Services (CMS). NCCI Policy Manual for Medicare Services - Effective January 1, 2018, Chapter 1.

Centers for Medicare & Medicaid Services (CMS), Specific Modifiers for Distinct Procedural Services. Medicare Learning Network.

Cross References

Bundling Edits

Urine Drug Testing

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.