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Modifier 59 and New Modifiers XE, XS, XP, XU

The Medicare National Correct Coding Initiative (NCCI) includes edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together.

A Correct Coding Modifier Indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.

One function of these edits is to prevent payment for codes that report overlapping services except in instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

The CPT Manual defines modifier 59 as a Distinct Procedural Service. 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 identifies procedures/services, other than E/M services and radiation treatment management, which 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)

Note: When another already established modifier is appropriate, report it instead of modifier 59. Use modifier 59 only if no other descriptive modifier is available.

Do not report modifier 59 or other NCCI-associated modifiers to bypass an edit unless documentation in the medical record supports its use.

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported.

Modifiers XE, XS, XP, XU defined

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”

Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, you may begin using them for claims with dates of service on or after January 1, 2015.

Note: You have the option to continue using modifier 59 in any instance in which it was correctly used prior to January 1, 2015. CMS' additional guidance and education as to the appropriate use of the new -X {ESPU} modifiers is forthcoming.

Until CMS provides official guidance, Novitas offers the following suggestions for the use of the -X {ESPU} modifiers, should you decide to use them.

As a reminder, your medical documentation must support the use of modifiers.

Examples

The examples below are from CMS' Modifier 59 article along with Novitas Solutions' suggestions for the optional use of modifiers XE, XS, XP, and XU beginning January 1, 2015.

Common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day, and cannot be described by one of the more specific anatomic modifiers, such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, LM, RC or RI.

Example 1

17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratosis) other than skin tags or cutaneous vascular proliferative lesions; first lesion

11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Modifier 59 may be reported with 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier does not apply.

If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used.

Modifier 59 is reported for different anatomic sites during the same encounter only when procedures, not ordinarily performed or encountered on the same day, are performed on different organs, different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XU may be more appropriate.

Example 2

47370 – Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Modifier 59 should not be reported with 76942 if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure.

Modifier 59 may be reported with 76942 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XU may be more appropriate.

Example 3

93453 – Combined right and left heart catheterization including intraprocedural injections(s) for left ventriculography, imaging supervision and interpretation, when performed

76000 – Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)

Modifier 59 should not be reported with 76000 for fluoroscopy used in conjunction with a cardiac catheterization procedure.

Modifier 59 may be reported with 76000 if the fluoroscopy is performed for a procedure unrelated to the cardiac catheterization procedure.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XU may be more appropriate.

The definition of different anatomic sites includes:

different organs, or
different lesions in the same organ

NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered separate and distinct. Therefore, modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit.

The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites.

Example 4

Treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site.

11055 - Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion

11720 – Debridement of nail(s) by any method(s); 1 to 5

Modifier 59 should not be reported with 11720 if a nail is debrided on the same toe from which a hyperkeratotic lesion has been removed.

Modifier 59 may be reported with 11720 if multiple nails are debrided and a corn that is on the same foot and that is not adjacent to a debrided toenail is pared.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XS may be more appropriate.

Example 5

Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site.

67210 – Destruction of localized lesion of retina (e.g., macular edema, tumors), 1 or more sessions; photocoagulation

67220 – Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), 1 or more sessions

Modifier 59 should not be reported with 67220 if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XU may be more appropriate.

Example 6

Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site.

29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

Modifier 59 should not be reported with 29820 if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure.

If the procedures were performed on different shoulders, modifiers RT and LT should be used.

Modifier 59 may be reported when the procedures are performed in different encounters on the same day.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XE may be more appropriate.

Modifier 59 may be reported with surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed during different patient encounters on the same day.

Example 7

93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report

93040 – Rhythm ECG, 1-3 leads; with interpretation and report

Modifier 59 may be reported if the rhythm ECG is performed at a different encounter than the cardiovascular stress test.

Modifier 59 should not be reported if a rhythm ECG is performed during the cardiovascular stress test encounter.

Do not report modifier 59 if the basis for its use is the narrative description of the two codes is different.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XE may be more appropriate.

Example 8

Common misuses of modifier 59 are related to the portion of its definition used to describe a different procedure or surgery. The description of the edit usually represents different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered separate and distinct.

34833 - Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral

34820 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral

Procedure code 34833 is followed by a CPT instruction that states, "Do not report 34833 in conjunction with 34820." Although the descriptors for 34833 and 34820 describe different procedures, they should not be reported together for the same side.

Modifier 59 should not be appended to either code to report the two procedures for the same side of the body.

If the two procedures were performed on different sides of the body, modifiers LT and RT should be reported as appropriate.

Modifier 59 should not be reported if the basis for its use is the narrative description of the two codes is different.

Modifier 59 may be reported if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date to indicate they are different procedures on that date of service.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifiers XE or XS may be more appropriate.

Example 9

There are limited situations where two services may be reported as separate and distinct. Separated in time and describe non-overlapping services, even though they may occur during the same encounter.

Modifier 59 is reported for two services described by timed codes provided during the same encounter when they are performed sequentially.

Modifier 59 is reported with codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour).

If two-timed services are provided that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), report modifier 59.

97140 – Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Modifier 59 may be reported if the two procedures are performed in distinctly different 15-minute intervals. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy.

Modifier 59 should not be reported with 97530 if the two procedures are performed during the same 15-minute time interval.

Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XE may be more appropriate.

Example 10

When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure, and a decision to perform the surgical procedure is made, that diagnostic test may be considered separate and distinct procedure as long as:

it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention;
it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and
it does not constitute a service that would have otherwise been required during the therapeutic intervention.

37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

75710 – Angiography, extremity, unilateral, radiological supervision and interpretation

Modifier 59 may be reported with 75710 if a diagnostic angiography was not previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography.

CPT defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery.

Modifier 59 is reported appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifiers XE or XU may be more appropriate.

Example 11

When a diagnostic procedure follows a surgical procedure or non-surgical therapeutic procedure, it may be considered a separate and distinct procedure as long as:

it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and
it does not constitute a service that would have otherwise been required during the therapeutic intervention.

32551 – Tube thoracostomy, includes connection to drainage system (e.g., water seal), when performed, open (separate procedure)

71020 – Radiologic examination, chest, 2 views, frontal and lateral

Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia.

Modifier 59 should not be reported with 71020 for a chest x-ray performed following insertion of a chest tube.

Modifier 59 is used appropriately for a diagnostic procedure, which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.

If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

The use of modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure. Different diagnoses are not adequate criteria for use of modifier 59.

The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other scenarios described above.

Novitas Solutions' suggestion: Beginning January 1, 2015, modifier XE may be more appropriate.

As a reminder, your medical documentation must support the use of modifiers.

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Last modified:  10/12/2017