Modifier 59, sub-modifiers XE, XP, XS, and XU
Modifier 59 Distinct Procedural Service: According to the CPT Guidelines, under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services that are normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different 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. However, when another already established modifier is appropriate it should be rather than modifier 59.Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances.
The Centers for Medicare and Medicaid Services (CMS) instituted a new subset of code modifiers, beginning January 1, 2015.
The new submodifiers are:
XE (separate encounter)
XP (separate practitioner)
XS (separate structure)
XU (unusual non-overlapping service)
According to CMS, the correct use of modifier 59 is:
?Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.
The new sub-modifiers should not be used with the psychological and neuropsychological testing code combinations:
96101 with 96102, or
96118 with 96119
Considering psychological and neuropsychological testing; modifier 59 (separate and distinct service) remains the most appropriate choice when billing the testing code combinations 96101 with 96102, or 96118 with 96119.
Reasons why these modifiers are not applicable for psychological and neuropsychological testing codes are:
? XE (separate encounter) applies when:
? Distinct services are provided during different encounters on the same date. In technician-administered testing, the additional time for integration of data from external sources is not a patient encounter.
? XP (separate practitioner) applies when:
? Different practitioners deliver the same service during an encounter. In 96102 and 96119, the technician is not the practitioner; the psychologist/neuropsychologist is the practitioner and the one whose name is on the claim.
? XS (separate structure) applies to:
? Procedures on different anatomic structures. This is not applicable to psychology/neuropsychology.
? XU (unusual non-overlapping service) applies when:
? A service is distinct because and does not overlap with the usual components of the main service.
Official CPT coding instruction (in the parenthetical statement that follows each of these code pairs) states that it is permissible to report 96101 with 96102, or 96118 with 96119. Providers should be careful to append modifier 59 to one of the reported codes. Coding guidance for Modifier 59 and its sub-modifiers (PDF, 131KB) is available from CMS. In this online document, CMS provides a number of examples of correct and incorrect uses of 59, and then follows with examples for the new X [EPSU] modifiers.
The -59 modifier is often used to bypass the National Correct Coding Initiative (NCCI) edits and is the most widely used modifier. In the transmittal, CMS states that the -59 modifier is associated with considerable abuse and high levels of audit activity, leading to reviews, appeals and civil fraud and abuse cases. They therefore are supplementing it with four new more distinctive modifiers, starting on January 1, 2015.
The four replacement modifiers are:
? XE Separate Encounter ? A service that is distinct because it occurred during a separate encounter. This will generally not be used for laboratory claims.
? XS Separate Structure ? A service that is distinct because it was performed on a separate organ/structure. The XS modifier is to be used when the same laboratory procedure is performed on more than one body site. Examples of this are wound cultures from separate parts of the body. Another example is skin biopsies from multiple sites.
? XP Separate Practitioner ? A service that is distinct because it was performed by a different practitioner. This will generally not be used for laboratory claims
? XU Unusual Non-Overlapping Service ? The use of a service that is distinct because it does not overlap usual components of the main service
The XU modifier is to be used when there multiple units of the same CPT(C) code, but the laboratory procedures are different. The best example of this is CPT 86003 which is used for allergen testing. All allergens use the same CPT, but the test can be for nuts, milk, grass, cats, etc. These are different tests that all use the same CPT code. Another example is an antibody test where an IgG and an IgM can be tested, but there is only one CPT code available. Once again, they are separate, distinct tests which use the same CPT code. CPT 82784, Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each is another example of this scenario.
CMS states that it will be improper to include both the -59 and an ?X? modifier on the same claim,
The -91 modifier is the other modifier that laboratories use. Usage will not change and the modifier will continue to be used for repeat laboratory testing. CMS has defined this as the same test repeated in the same day or a test that is a component of a panel being repeated on the same day.
It is important to note that these new modifiers are for use only in the Medicare program.
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