Reminder: Use modifier 59 and related X modifiers for Medicare Plus Blue claims appropriately

When appending modifier 59 and related X modifiers on Medicare Plus Blue℠ claims, continue to follow the guidelines communicated in the September 2021 Record article. We’ve begun editing claim lines when modifier 59 and related X modifiers are appended on Medicare Plus Blue claims.

Our edits align with the Centers for Medicare & Medicaid Services’ National Correct Coding Initiative, or NCCI, program, and help ensure the correct coding of services. Modifier 59 and related X modifiers are used to indicate that a procedure or service was distinct or independent from other services that aren’t normally reported together but are performed on the same day.

We no longer automatically allow payment for certain procedures billed with modifier 59 and related X modifiers when billed with a procedure code on CMS’ NCCI Procedure‑to‑Procedure coding edits list.** Only select codes allow modifier 59 and related X modifiers to automatically bypass the NCCI code pair edits.

CMS provides more information on the proper use of modifier 59 and  related X modifiers on this Medicare Learning Network Fact Sheet.**

The related X modifiers are defined below:

• XE – “Separate Encounter, a service that is distinct because it occurred during a separate encounter.” Only use XE 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.”

The additional review assures claims have been coded correctly for more complex situations where an overriding modifier has been appended. Providers should code claims to the level of specificity for the services rendered and appropriately append diagnosis codes and modifiers following the guidelines published by the American Medical Association and CMS. The reported services should be supported in the patient’s medical record.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form or on Availity Essentials with the necessary documentation. Also, continue to fax one appeal at a time to avoid processing delays.

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