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Radiology/Imaging Program Guidelines for Use of Modifier 59

Code Definition

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Evaluation and Management (E&M) services performed on the same day. Modifier 59 is used to identify procedures and/or services, other than E&M services, that are not 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 (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

Horizon’s Reimbursement Policy #023 discusses Modifier 59. This modifier is allowable when used appropriately for radiology services.

It may also be used with surgical or medical codes in appropriate circumstances.

  • Modifier 59 is used to identify a separate service provided to a different anatomic site or a separate service provided on the same day, by the same physician during a separate patient encounter. Modifier 59 is the “modifier of last resort” and should only be used if a more descriptive modifier does not exist.

    When billing, report the first code without a modifier. On subsequent lines, report the code with the modifier.

  • Modifier 59 does not provide for reimbursement of an ineligible service, and no additional reimbursement will be issued for services if the reimbursement to the physician is via capitation.

  • Modifier 59 is recognized as appropriate when billed with obstetrical ultrasounds, CPT® procedures codes 76813 through 76828.

Use of XE, EX, XP and XU

Modifiers XE, XS, XP, and XU were developed to provide greater reporting specificity in situations where Modifier 59 was previously reported and may be used in lieu of Modifier 59 whenever possible. (Modifier 59 should only be used if no other more specific modifier is appropriate). Although the National Correct Coding Initiative Program (NCCI) will eventually require use of these modifiers rather than modifier 59 with certain edits, providers may use them for claims

The modifiers are defined as follows:

  • XE: “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  • 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”

Horizon claims payment rules combine those services that are considered an integral part of other services. For those services, Modifier 59 is not appropriate. Documentation must support a different service/procedure and separate patient encounter.