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Distinct Procedural Service Modifiers

Reimbursement Policy:

Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)

Effective Date:

January 1, 2009

Last Revised Date:

January 25, 2017

Purpose:

Provide guidelines for the recognition of distinct procedure modifiers when appropriately appended to procedure codes, other than Evaluation and Management (E & M) services that are not normally reported together. This policy applies to professional providers.

Scope:

All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

  • Modifier 59: Used to identify procedures or services, other than E & M services, that are not normally reported together but are appropriate under the circumstances; used if no other more specific modifier is appropriate.
  • Modifier XE: A distinct procedure performed during a separate encounter; used in lieu of modifier 59 (eff. 1/1/2015).
  • Modifier XP: A distinct procedure because it was performed by a different practitioner; used in lieu of modifier 59 (eff. 1/1/2015).
  • Modifier XS: A distinct procedure because it was performed on a separate organ/structure; used in lieu of modifier 59 (eff.1/1/2015).
  • Modifier XU: A distinct procedure because it does not overlap usual components of the main service; used in lieu of modifier 59 (eff. 1/1/2015).

Policy:

In accordance with The Centers for Medicare and Medicaid Services (CMS), Horizon BCBSNJ shall recognize procedures, other than E & M services, that are not normally reported together when appropriately appended with distinct procedural service modifiers when rendered by the same provider (except when using modifier XP), for the same patient, on the same date of service.

Examples of appropriate use of Modifiers XE, XP, XS and XU include, but are not limited to:

  • Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
  • Documentation indicates the services were provided during separate patient/provider encounter (Modifiers XE only)
  • Documentation indicates the services were provided by different practitioners with the same specialty in the same group practice (Modifier XP only)
  • Documentation indicates the services were provided on different organs/structures (Modifier XS only)
  • Documentation indicates the service was not part of the usual components of the main service (Modifier XU only)
  • Use Modifiers with the Column 2 procedure code in the NCCI files
  • Use Modifiers only when there is no other modifier to describe the situation

Examples of inappropriate use of Modifiers XE, XP, XS and XU include, but are not limited to:

  • Code pairs are not part of the NCCI procedure to procedure edits
  • If another valid modifier exists to identify the performance of the services by different practitioners
  • Submission of E/M Codes
  • Submission of Weekly radiation therapy management codes (CPT 77427)
  • The NCCI code files show the modifier application as "0"
  • Documentation does not support the services were provided during a separate patient/provider encounter. The patient did not leave and come back for the secondary service. (Modifier XE)
  • Documentation does not support the services were provided by different practitioners (Modifier XP Only)
  • Documentation does not support the services were provided on a separate organ/structure. (Modifier XS). For example; both procedures were performed on the liver during one encounter.
  • Documentation supports the service is a component of the main service (Modifier XU)
  • Exact same procedure code performed twice on the same day
  • Multiple administration of injections of the same drug
  • Submitted with Modifier 59

Examples of appropriate use of Modifier 59 include, but are not limited to:

  • Documentation indicates two separate procedures performed on the same day by the same physician. This is represented by a different session or patient encounter, different procedure or surgery site, or a separate injury (or area of injury).
  • Use with the secondary, additional or lesser procedure or combinations listed in National Correct coding Initiative (NCCI) edits.
  • Using when there is no other appropriate modifier
  • Use on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service.

Examples of inappropriate use of Modifier 59 include, but are not limited to:

  • Appending to E & M services
  • Code combination not appearing in the NCCI edits.
  • Reporting with radiation therapy management codes
  • The NCCI tables list the procedure code pair with a modifier indicator of “0”
  • Documentation does not support separate and distinct status
  • Exact same procedure code performed twice on the same day
  • Multiple administrations of injections of the same drug.
  • Using when a more descriptive modifier exists

In accordance with Office of the Inspector General (OIG) recommendations and in accordance with our provider contracts Horizon BCBSNJ shall perform post payment audits to verify proper utilization of distinct procedural modifiers. OIG encourages carriers to emphasize that appropriate documentation of both procedures must be maintained to support claims for payments using distinct procedural modifiers, even though documentation is not required to be submitted with the claims. OIG also encourages carriers to re-examine their distinct procedural outreach activities and include distinct procedural reviews in their medical review strategies where appropriate.

Procedure:

Recognize and consider for reimbursement procedure codes, other than E & M codes, that are not normally billed together when appropriately appended with a distinct procedural modifiers, when rendered by the same provider(except when using Modifier XP), to the same patient on the same date of service.

In instances where the provider is participating, based on member benefits, copayment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:

3/29/2009: Policy Approved

1/25/2017: Updated Procedure Section to include Appropriate/Inappropriate use for Modifiers XE, XP, XS, XU} and updated same for Modifier 59.

Policy 023_v2.0_01252017