CPT Modifier 59, XE, XS, XP and XU

[Laureen]

I've been getting a lot of questions about modifier 59 changes going into effect January 1st 2015 for CMS.

First here are some resources:

• Transmittal 1422 - CMS Manual Pub 100-20 - One Time Notification - where it all began
• MLN Matters® Number: MM8863
• Modifier 59 Article by CMS - gives insight into the history of 59 with CMS and why they felt the need to introduce the new X modifiers
• Article by JoAnne Sheehan, CPC, CPPM, CPC-I, CCO Instructor
• AAPC Article
• 2005 Article from the OIG - shows they've been having their eye on this for some time

Key Take Aways:

The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of
circumstances, such as a use to identify different encounters, different anatomic sites, and distinct services.
Usage to identify a separate encounter is infrequent and usually correct; usage to define a separate anatomic
site is less common and problematic; usage to define a distinct service is common and not infrequently
overrides the edit in the exact circumstance for which CMS created the edit in the first place. CMS believes
that more precise coding options coupled with increased education and selective editing is needed to reduce
the errors associated with this overpayment.

citation

CMS will continue to recognize the -59 modifier, but notes that Current Procedural
Terminology (CPT) instructions state that the -59 modifier should not be used when a more
descriptive modifier is available. While CMS will continue to recognize the -59 modifier in
many instances, it may selectively require a more specific - X{EPSU} modifier for billing
certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code
pair may be identified as payable only with the -XE separate encounter modifier but not the
-59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of
the -59 modifier so it would be incorrect to include both modifiers on the same line.

citation

 

[AnnaB]

Will these modifiers be used for medicare only? I was just reading the current heakthcare business montly.

Thanks,
Anna

 

[Laureen]

Hi Anna,

Yes these new X modifiers are for Medicare only at this point but it's likely other payers will follow suit. You'll have to look for direction from your payers. It's also important to note that Medicare is not saying they won't accept modifier 59 but if any of the new 4 modifiers fits your situation better then you are to use those.

Happy Coding!

 

[AnnaB]

Hi Anna,

Yes these new X modifiers are for Medicare only at this point but it's likely other payers will follow suit. You'll have to look for direction from your payers. It's also important to note that Medicare is not saying they won't accept modifier 59 but if any of the new 4 modifiers fits your situation better then you are to use those.

Happy Coding!

thanks Laureen

 

[Ruth Sheets]

Jo-Anne Sheehan talked about the new modifiers replacing -59 for Medicare in the November 2014 Q&A Webinar and also gave some examples on how to use them. Here is a brief description:
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.

If you missed the webinar, it is a great idea to sign up for the CCO Club. That way you will get access to the recording of the webinar, conveniently divided into video clips by topic. You also get the transcript, answer sheets, and a chance to earn a CEU for the webinar by passing a 10 question quiz. Not only that, but you can access all the available resources for past webinars, too!