The Proper Use of Modifiers 59 & –X{EPSU}

The Medicare National Correct Coding Initiative (NCCI) provides PTP (Procedure-to-Procedure) edits that stipulate when providers aren’t allowed to report certain HCPCS or CPT codes together. Here are the key points: 
  • In the case of NCCI PTP-associated edits with a correct coding modifier indicator (CCMI) of “0”, the codes shouldn’t be reported together by the same provider for the same beneficiary on the same date of service. When the codes are reported together on the same date of service, the code on Column One would be eligible for payment, but Medicare would reject the Column Two code. 
  • In the case of NCCI PTP-associated edits with a CCMI of “1,” the codes may be reported together using specific NCCI PTP-associated modifiers but only in stipulated circumstances. 
NCCI PTP-associated edits help to prevent payment for codes that report overlapping services apart from a situation where the services are “separate and distinct.” Modifier 59 is one useful NCCI PTP-associated modifier, but providers usually misuse it. 

The definition of Modifiers 59, XE, XP, XS, and XU

According to the CPT Manual, Modifier 59 is to be used for “Distinct Procedural Service!”

Let’s explain: In some situations, a provider may need to indicate that a procedure or service was distinct from another non-E/M (Evaluation/Management) service rendered on the same day. The provider can use Modifier 59 to identify procedures/services, other than E/M services, which are not normally reported together but can be allowed under the circumstances. However, documentation must show 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. But another established modifier, other than modifier 59, should be used if appropriate. Modifier 59 is used only if no more descriptive modifier is available and its use best explains the situation.
Modifiers XE, XS, XP, and XU were introduced on January 1, 2015. They give greater reporting specificity in situations where modifier 59 was previously used. 

Appropriate & inappropriate use of these modifiers

  1. You use modifiers 59 (or –XS) appropriately — for different anatomic sites during the same encounter — only when procedures that are not usually performed on the same day are performed on different organs or different anatomic regions or, in rare cases, on different, non-contiguous lesions in different anatomic regions of the same organ
  2. You use modifiers 59 (or –XE) only when no other modifier more effectively describes the relationship of the 2 procedure codes. You may also use modifiers 59 or –XE for diagnostic procedures, surgical procedures, or non-surgical therapeutic services that are rendered during different patient encounters on the same day, which can’t be reported with any of the more specific NCCI PTP-associated modifiers, such as 24, 25, 27, 57, 58, 78, 79, or 91. 
  3. You should not use modifiers 59 (or –XU) just because the code descriptors of the 2 codes are different. When the code descriptors of the 2 codes of a code pair edit describe different procedures, even if they overlap, don’t report the 2 codes together even if they’re performed at the same anatomic site and same patient encounter. They can’t be considered “separate and distinct.” Thus, don’t use modifiers 59 (or –XU) to bypass a PTP edit because the 2 codes are “different procedures.”
  4. There are other specific proper uses of modifiers 59 (or –XE or XU)
     A. Modifiers 59 (or –XE) is used properly for 2 services described by timed codes provided during the same encounter only when they are performed one after another.
     B. Modifiers 59 (or –XU) is appropriately used in the case of a diagnostic procedure that is performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
    C. Modifiers 59 (or –XU) is appropriately used for a diagnostic procedure that is done after a completed therapeutic procedure only when the diagnostic procedure isn’t a necessary follow-up to the therapeutic procedure.