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Medicare 59 Modifiers – XE, XP, XS, XU

Medicare Modifiers 59 Subset XE XP XS XU

Four New Modifiers to Use Instead of Modifier 59 – XE, XS, XP & XU

Proper modifier usage can be one of the biggest hurdles to filing a clean claim. Medicare recently announced they’ve established four new modifiers – XE, XS, XP, and XU – that may be used in lieu of modifier 59. The codes are more specific and become effective January 1, 2015.

To start, let’s quickly define the four newest HCPCS modifiers, also commonly referred to as -X{EPSU} modifiers. The acronym EPSU is made up of the last letter of the new modifiers.

Medicare X{EPSU} Modifiers XE XP XS XU

Modifier XE

Separate Encounter: A service that is distinct because it occurred during a separate encounter.

Modifier XP

Separate Practitioner: A service that is distinct because it was performed by a different practitioner.

Modifier XS

Separate Structure: A service that is distinct because it was performed on a separate organ/structure.

Modifier XU

Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap the usual components of the main service.

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What is Modifier 59?

Modifier 59 is used to define a “Distinct Procedural Service.” These are procedures and services performed by a healthcare provider that are not typically reported together, but are appropriate and separately billable given the circumstances.

When modifier 59 is appended to a CPT code, it indicates that the service is separate and distinct from another service with which it would usually be bundled. The modifier allows the claim to pass Medicare bundling edits, resulting in additional reimbursement for the physician. Modifier 59 can be used to indicate a variety of situations including:

• Different encounters;

• Different anatomic sites; and

• Distinct services.

It’s also important to remember that modifier 59 should not be attached to an E/M service.

Why New Modifiers?

Modifier 59 is not only the most used modifier, but it’s also the most abused. And while the abuse may be unintentional at times, the improper coding leads to incorrectly paid claims. As audits have increased, CMS has realized that more specific modifiers may be helpful in deterring this abuse.

The -X{EPSU} modifiers are essentially a subset of modifier 59. CMS believes their usage will help reduce overpayment errors.

How to Use the –X{EPSU} Modifiers

Modifier 59 is not going away and will continue to be a valid modifier, according to Medicare. However, modifier 59 should NOT be used when a more appropriate modifier, like a XE, XP, XS or XU modifier, is available. Certain codes that are prone to incorrect billing may also require one of the new modifiers.

CMS is encouraging providers to adopt the modifiers quickly; they may be used by Medicare and considered valid even before national edits are in place on January 1st.

Additional Information

Medicare Learning Network: MLM MM8863

Manual System: Transmittal 1422

Here is a link to my other post with some examples of how to use the new modifiers. CLICK FOR MODIFIER EXAMPLES

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68 thoughts on “Medicare 59 Modifiers – XE, XP, XS, XU”

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    Hello Dr. Oliverez,
    We use CPT codes 99214, 62369, and J0475 (on the same claim) for patients we see with Intrathecal Baclofen Pumps in office. Until recently, these 3 lines paid with simply MOD 25 on 99214. Wondering if we are to use MOD 59 or one of the XE, XP, XS, XU for 62369 (Electronic Analysis & Refill of Baclofen Pump by Nurse). Thanks for your thoughts.

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    Oh my goodness, I have been trying to bill Medicare every which way for CPT 98940 and 97140 with the new modifiers, but 97140 keeps denying. Please help. Thank you for your time.

    98940-AT 1 UNIT, 97140- GP, XP 4 UNITS

    Sincerely,
    Julie Eggleston

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      I ran the two codes, 98940 and 97140, through CCI edits software and there was a conflict between the two codes. A warning came up that these two codes cannot be billed together.

      What are the denial reasons?

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    My providers are an Optometrist and an Opthalmologist, both under the same group tax id#. If the optometrist does a visual exam, then refers the patient to the opthalmologist for an excision on the same day, is the XP modifier a valid one to use, and for which provider?
    Thanks very much!

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    Melissa Neikirk

    How should I bill a trigger point injection of J1020 with an infusion that was given the same day? The trigger point injection was given by the APRN.
    20552 (XE)
    J1020

    The infusion must be billed under the physician.
    J1745
    96413 (XP)
    96415

    Any help would be appreciated.
    Melissa

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    I am with Hospice services and we pay Medicare rates, what if I cant find a rate to pay on an invoice from the hospital for 96376XU or other HCPCS codes?

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    Should the XP Modifier be added for the PA/APRN to the Physician consult charge 99233 for their portion of the consult note?

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    Do we need to put XU on each line item? Except.: radiology
    MRI
    RMA
    X-ray

    Claim has been rejected…do we need to put an XU Modifier on each line

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    We do both physican and facility billing. Podiatry billing is very tricky by the way 🙂 For the physican side we use 59 and Q9 for 11721 and only Q9 for 11057 and get paid separately no problem and patient owes nothing or close to nothing. For the hospital facility charge XS and Q9 is used for 11721 and Q9 for 11057. Medicare bundles 11721 and 11057 when the XS modifer is used so the pt owes $44.07. My question is: can 59 modifer still be used for hospital facility setting?

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    Thank you. I was just wondering if the new list of modifier options XS XP XU that were eff 2015 actually cleared the insurance company input if claim billed chgs with those attd. Some of the insurance companies were not clearing claims months after though they were suppose to clear into pmt. The 59 I read on then was still a modifier to use if the condition procedure required it but a deleted modifier. I saw the 59 as needing a separate reason in addition to something that requires the distinct procedure .

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    I would like clarification of the separate structure…I understand if a procedure is done on the right hand and the other is done on the left knee…what would doing a medical meniscus repair on the right knee and a lateral meniscectomy on the same knee…but different compartments…would you use the XS then? also what about repair of two extensor tendons of the same hand? would two separate tendons be considered a separate structure even though on the same hand?

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    I saw a claim billed as 99214 with a 25 modifier and and ekg 93000 billed with an XE modifier. I had not seen that before and just wanted to understand why the XE was needed on the claim. No other services were billed the same day. Thank you

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    I am a little confused when it comes to which modifier to use if billing a colon (45378) and EGD (43239) when We do both at the same time. Should we be using the XS modifier?

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    Hi could you please tell me if I’m billing this correctly? A pt is here for her annual and also nutrionist consult.
    99214 25
    97750 GO
    82948
    G0108 XU

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    There is some debate among the coders at a hospital I work for. Here is an example of what we are confused on:

    Medicare ED pt gets infusions and injections…96365 and 96372. Or same pt gets infusions/injections with foley. We normally use modfier 59 on 96372, and on infusion/injections with foley. Some coders want to still use mofifier 59, and others want to use XU. I don’t see how infusions/injections are unusual so I am in the 59 camp. What do you think? I am wondering if the new modifiers are mainly for surgeries?

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      Hi, was wondering if you have gotten a reply or any other input regarding your question. I myself am having the same concern/confusion on which modifier we should be using. Any info you may have would be greatly appreciated :)…

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    Hello again,

    I have been reading over these new modifier rules again and of course have over thought the whole process. When doing Colonoscopies ie: 45385 with 45380 etc, would you use the XS or XU. Initially I thought XS but after more reading and thought I am leaning towards XU. Thoughts please

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      If this was a 45380, colonoscopy, flexible; with biopsy, single or multiple, and 45385, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, are usually not billed together as I understand.

      I think I may not be understanding your question.

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        The 45385 and the 45380 are billed together when a polyp removal is done in separate areas of the colon. In the past a 59 was applied toe the 45380 but since the Medicare changes there is some confusion as to whether we use the XU or the XS.

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    Premera Blue Cross is requiring the use of the new modifiers too; however, they are willing to accept 59 if no other modifier is more appropriate.

    So it appears to me that the distinct but separate service would now be XU.? Please correct me if I am misreading it. For example exercise therapy, therapeutic activities, and manual therapy all preformed on the R knee.

    97530 XU
    97140
    97110

    Changing the modifier from 59 to something else would be an easy transition if all insurance companies were on board with the new modifier.

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      Shari all carriers will accept modifier 59. However you need to use the new X modifiers if they are more specific than the 59.

      In the case above I would still use modifier 59. When I think of the XU modifier I think of a diagnostic procedure being performed and then based on the findings of the diagnostic procedure, a therapeutic or surgical procedure is done on the same day.

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    We were told that all of Tricare were accepting the new X modifiers. Now that may be for the region we are in, but who knows for sure right now….

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        I don’t think my supervisor had seen anything in writing either, but had heard the rumor so she called our local Tricare rep.

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    Does anyone know if other insurance companies are going to require these codes or is it just Medicare. For physiotherapy done on the same day, same physician would I use XS or XU. Any thoughts . 97010, 97012, 97014

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      At the moment only Medicare requires the new modifiers. Insurance companies often follow Medicare rules so I would not be surprised if in the future some commercial insurance carriers will require the new modifiers.

      Make sure you read any info you get from insurance companies and check their websites monthly to see if they have any updates to their billing policies. They should let you know of any changes….usually…sometimes…maybe ..or not. You know how they work.

      For the second part of your comment I would still use modifier 59.

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    Can you please verify if I am coding this scenario correctly? A patient came in for her 6month extended office visit for HTN, Hyperlip, OA, GERD, etc. She received a knee injection at the same office visit and a B12 injection. This is how I have coded it:

    99215 25
    J3301
    20610 XS RT
    J3420
    96372 XS

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      Tonya based on the information provided I would bill as follows:

      99215-25
      J3301
      20610
      J3420
      96372

      We bill these codes and have never used a modifier. Also make sure to apply your DX codes to the correct corresponding CPT code.

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    Which -X{EPSU} modifier would be appropriate for a post-operative pain injection performed by the anesthesia provider. For example, anesthesia is provided for a shoulder replacement, surgeon requests that anesthesia provide a separate injection to control post operative pain. In the past, -59 has been used to indicate the distinct procedure for the injection.

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      In my opinion based on your scenario I would use the XU modifier. XE would not apply becasue it is not a separate encounter. Nor would XP since it is not being performed by 2 different practitioners. Probably not XS since your were working on the same anatomical site. XU possibly since it is the same encounter, the same practitioner and be considered the same site.

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    This is my take on XS, non-contiguous lesion in different anatomic region of the same organ. And that modifier 51 is a bone of contention with me. We are made to put it on our multiples, and are told it is carrier specific. 🙁

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    I do use modifier 59 with a lot of my colonoscopies, because the guidelines say if you take a lesion from the sigmoid by snare and then you find another lesion in the rectum and just do a biopsy, then you can code that as well. So my charge would read as
    45385
    45380-59-51
    And depending on if it started as a screening, I then consider the modifiers. But these new modifiers have me baffled, esp. XS and XU

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      Yes, we would code both the 45385 and 45380-59 also. We don’t use the 51 modifier since these codes apply the multiple reduction. Since you stated sigmoid and rectum, maybe they do count as different anatomical sites.

      Coding is so subjective. I wish it were more black and white.

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        Anne you are so right about coding being subjective. I’ve had one coder code one way and another code differently. On top of that we have to then modify the codes to meet with the insurance companies guidelines on how they want things coded for claim submission.

        Fun stuff.

        Thanks for chiming in on these threads.

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    Hi,
    would you use any of the new modifiers with bronchoscopies? Example

    31629,31620,31628,31624,31627,31633, 31633 and on another note, how about colonoscopy

    45385 with 45380 or 45385 with 45382
    thank you,
    Sharon Whitehurst CPC,LPN

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      I’m interested to see what get said about this. My thought is no, you would continue to use the 59 modifier. The only thing that gives me pause is the different anatomical site of the XS modifier. To me, the colon is the colon, no matter where you are on it, so the XS wouldn’t be a valid option. I also wouldn’t pick the XU since the diagnostic procedure is rolled into the therapeutic code.

      The bronchoscopy might be another matter since you have two lungs 🙂 and there is more of an argument for different anatomical sites.

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        No not missed Sharon just behind.

        You can rule out using modifier XE for the bronchoscopy codes since it is not a separate encounter and XP since it is not a separate practitioner. XS would not be appropriate becasue the procedures are performed on the same organ system (respiratory)

        That would leave us with modifier XU or 59 to use.

        You could make a case for XU but I would use 59 since it is the same encounter, on the same organ system, and you are not doing a diagnostic procedure followed by a therapeutic or surgical procedure.

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          Thank you for your response. That is what I was also thinking. All the changes should be very interesting and coding is so subjective and I tend to over think everything.

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    Nancy Grandmaison

    Modifier help with spine surgery multi levels. Example:
    22600,22614x 63045,63048×4. Not sure if I should use XS differ structure. Descriptions of XS and XU are very confusion for proper usage with certain code combinations like add on or distinct service (not included). If someone has other examples or better description.

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      Hi Nancy,
      I just received some denials from Medicare for the additional laminectomy codes 63048, which were billed with -76. I was wondering myself if XS is the new modifier I should be using….have you (or anyone else) tried the new modifier & if so, have they paid? Thanks in advance.

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    Tanya Esquivel, CCS

    Codes 52214, 52318 and 52005 were performed at the same encounter with the same practioner. My edits tell me that 52005 needs a modifier. What modifier would you use?

    Thank you

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      I think of structure as appendage/limb or organ. This gets a bit confusing when you are talking about the skin…so that’s where I would go with appendage. What do you think?

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        Do you think that a drug infusion done in the left arm and then a drug infusion done in the right arm would require the modifier XS? I am thinking of an ED patient who has more that one IV access site done on the same date of service.

        I think it would if you consider a limb a stucture.

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          I agree and would append Modifier -XS. Hopefully we can get a few other opinions as this is a really good scenario example!

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            I ran this thru 3M today and I think I’m wrong about using modifier XS. It looks like you would still us modifier 59. 3M even tells you to use the 59 modifier. I got a message box that says “you may append modifier 59 on the second initial if it is for a… second site per protocol.”

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    This is very helpful, Manny! Would it be possible to post an example for each of the X’s? Also, will commercial insurances be recognizing these also? Lastly, will these be used for Hospital Billing as well as Provider Billing? Thanks so much for your help!!!

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      Laura —

      Thank you. Great suggestion on having examples of each new X modifier. I write a new post on that before the beginning of the year.

      Currently these new modifiers are just for Medicare. But as you know commercial insurance often follows what Medicare does so I would not be surprised if down the road some do adopt the X modifiers.

      Yes as far as I know the modifiers should be used for both hospital and office visits.

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      The XU modifier states:
      Unusual Non-Overlapping Service. The use of a service that is distinct because it does not overlap usual components of the main service.

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      Hi Jalpa —

      Modifiers XE, XP and XS look straight forward. I can see how the XU modifier would raise some questions on its use so lets see if I can help.

      Say a provider is performing a cardiac diagnostic test and as a result of that test a cardiac procedure is performed. You would not use the XE modifier since the procedure was not done at a separate encounter. Like wise you would not use the XP modifier becasue the procedure was not done by a separate practitioner. Neither would it be correct use the XS modifier due to the fact that the procedure is not being performed on a separate organ/structure.

      Therefore in this case a XU modifier would be appropriate.

      But here is the kicker, a 59 modifier would also be appropriate.

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        Hi,
        in the past we would use MOD -59 for 1st 93005 and 2nd performed on same DOS either if same physician or different -76 or -77. So I have this edit 33249/93005 X2 would you report same way? Let’s assume both EKGs were performed on same DOS and same MD? and in another representation. the 2nd EKG was performed on same day but different MD? That way I can cover both situations.

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