Subject: Modifiers 59 and XE, XP, XS & XU (Distinct Procedural/ Separate/ Unusual Service) NY Policy: 0023 Effective: 08/22/2016 11/20/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. DESCRIPTION A modifier is made up of two alpha and/or numeric characters that are appended to a Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System Level II (HCPCS) code. A modifier is used as a means of reporting a specific circumstance that further defines or alters the code but it does not change the definition of the procedure performed or item procured. Modifier 59 is described by CPT as identifying a distinct procedural service. Appendix A of the CPT Manual states that 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/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 1 Modifiers XE, XP, XS, and XU (referred to collectively as X{EPSU} modifiers) are described by HCPCS as modifiers to be used for a distinct separate encounter (XE), separate practioner (XP), separate structure (XS), or unusual non-overlapping service (XU) and are considered subsets of modifier 59 for selective identification. This policy documents the Health Plan s position on reimbursement and reporting services with modifiers 59, XE, XP, XS, or XU. POLICY The Health Plan accepts modifier 59 for claims processing, but not always to determine reimbursement. Modifier 59 and X{EPSU} are important to the adjudication of the claim because it may result in the override of edits within the Procedure Unbundling ClaimsXten Rule. I. Procedure Unbundling: occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. Procedure unbundling edits include three components: Incidental, Mutually Exclusive, and Rebundling. See also our Claim Editing Overview Policy for additional ClaimsXten rule information. NY 0001 Page 1 of [5]
When modifier 59 or X{EPSU} are appended to a reported procedure code, our claims editing system will override most incidental, mutually exclusive, and rebundling denials, and allow separate reimbursement for that procedure. The incidental, mutually exclusive, and rebundling edits are not overridden when a different diagnosis is submitted, with a line item procedure code, without a modifier to identify a distinct procedural service. However, a different diagnosis alone does not justify the use of modifiers 59 or X{EPSU}. Unlisted procedures are not affected by modifiers 59 or X{EPSU}. II. Reporting and Documentation Rules and Criteria for Modifier 59: The reporting of modifier 59 or X{EPSU} by a provider must follow the Health Plan s requirements for correct coding. The Health Plan requires that modifier 59 or X{EPSU} must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits We follow CPT coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. 2 Documentation is not required for a claim to be processed when modifier 59 or X{EPSU} are appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. The Health Plan follows CPT in requiring that documentation must support: a different session or patient encounter a different procedure or surgery a different anatomical site or organ system a separate incision/excision a separate lesion a separate injury The following example indicates the appropriate use of modifier 59 or an X{EPSU} modifier when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported. A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71010 will be denied separate reimbursement. When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 or XE to CPT 71010 is warranted to signify that a separate and NY 0001 Page 2 of [5]
distinct service was performed. (Modifier 59 or XE should follow modifier 26, if services are done in a facility setting.) Modifier 59 or XE will override the procedure unbundling edit and 71010 will be eligible for separate reimbursement. III. Exceptions to Distinct Modifier Override: The Health Plan has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 or X{EPSU} to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending distinct procedural modifier to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement (See also our Screening Services with Evaluation & Management Services and our Bundled Services and Supplies reimbursement policies.): Duplicate coding Services and supplies specified in the Bundled Services and Supplies Policy E/M or DME item codes National Correct Coding Initiative (NCCI) edit code pairs with a superscript of zero, or a modifier allowance indicator of zero. When the denial of a code is supported by CPT parenthetical language that indicates a code is not reportable with specific other code(s) (e.g., do not report xxxxx with yyyyy...), distinct procedural service modifiers will not override the denial In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples: 1. 01996 reported with 62310-62311 2. 29875 reported with 29880, 29881, 29882 and 29883 3. 36000 reported with 96360, 96365, 96374, 96375, 96376, 96405, 96406, 96409, 96413, 96416, 96440, 96446, 96450, and/or 96542 4. 36591 and 36592 reported with E/M codes 99201-99215, 99222-99226 and 99241-99255 5. 58140, 58145, 58146, 58545, 58546 and 58561 reported with 58570, 58571, 58572 or 58573 6. 58570, 58771, 58572 or 58573 when reported with 58146 7. 59620-59622 reported with 59618 8. 59514-59515 reported with 59510 9. 63042 and 63047 reported with 22630 or 22633, same interspace 10. 63081-63088 with 22551, 22552, 22554, 22585 and 63090-63091 with 22612, 22614, 22558, 22585, 22633 and 22634 (unless limited circumstances are met, such as spinal fracture, spinal infection, or spinal tumor) 11. 700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (These code ranges include all applicable radiology interpretation codes, as well as radiology codes with modifier 26) reported with 99221-99233 and 99281-99285 12. 75894 reported with 36471 NY 0001 Page 3 of [5]
13. 76098 reported with 19081-19086 14. 76872 reported with 76965 15. 76942, 77002, 77003, and 77012 that are indicated as not reportable with specific other codes per CPT parenthetical statements (e.g. do not report 76492 in conjunction with ) 16. 77014 reported with 77280, 77285, and/or 77290 17. 80321 reported with 80322; 80324 reported with 80325 and 80326; 80325 reported with 80326; 80327 reported with 80328; 80329 reported with 80330 and 80331; 80330 reported with 80331; 80332 reported with 80333 and 80334; 80333 reported with 80334; 80335 reported with 80336 and 80337; 80336 reported with 80337; 80339 reported with 80340 and 80341; 80340 reported with 80341; 80342 reported with 80343 and 80344; 80343 reported with 80344; 80346 reported with 80347; 80350 reported with 80351 and 80352; 80351 reported with 80352; 80362 reported with 80363 and 80364; 80363 reported with 80364; 80369 reported with 80370; 80375 reported with 80376 and 80377; and 80376 reported with 80377 18. 82541, 82542, 82543 and/or 82544 reported with 80300-80304 and 80320-80377 19. 82570 reported with 80300-80377, 83992, and G0480-G0483 20. 83986 reported with 80300-80377,83992, and G0480-G0483 21. 88305 reported with G0416 22. 93010, 93018, 93042, and 0180T reported with 99281-99285 23. 95940 reported with 95941 24. 96110 reported with 99420 25. 96365, 96369, 96372, 96373, 96374, and 96379 reported with nuclear medical testing codes 78000-79999 26. A4215 reported with 97810-97814 27. A4221, A4222, E0776, E0781 and S9810 reported with any per diem home infusion therapy (HIT) code such as S5492-S5502, S9061, S9325-S9379, S9490-S9504, S9537- S9590. 28. A4250 reported with urinalysis codes 81000-81003 29. A4556 and A4557 reported on the same date of service and/or within a 30 day period with electrical stimulator supplies code A4595 30. A4556 reported with related electrical cardiography codes 93XXX, neurology, sleep study and neuromuscular codes 95XXX; electrical stimulation codes 97014, 97032-97033, 97813-97814; and home sleep studies G0398-G0400 31. A4595 reported with 97014, 97032 32. A4648 reported with 19081 19101 and/or 19281-19288 33. G0268 reported with 92550-92558, 92561-92588, 92596 34. H2019 reported with H2020 35. J2001 reported with 20526-20615, 27096, 64470-64495 NY 0001 Page 4 of [5]
36. Q0091 reported with 99381-99397, 99201-99215, and S6010-S6013 1Current Procedural Terminology, cpt 2016, Professional Edition, pg. 710 2Ibid CPT is a registered trademark of the American Medical Association ClaimsXten is a registered trademark of McKesson Information Solutions LLC Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. 2016 Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield. NY 0001 Page 5 of [5]