Update: Reminder of appropriate use of modifier 59 and related X modifiers for Medicare Plus Blue claims

In the June Record, we communicated about the appropriate use of modifier 59 for Medicare Plus Blue℠ claims. We’ve updated the article to indicate that the guidelines that apply when appending modifier 59 also apply to related X modifiers. Use the revised article below as your reference going forward.

As a reminder, you’ll want to continue to follow the guidelines communicated in the September 2021 Record article when appending modifier 59 Medicare Plus Blue℠ claims — and keep in mind that the guidelines also apply to related X modifiers. We’ve begun editing claim lines when modifier 59 and related X modifiers are appended on Medicare Plus Blue claims.

This change aligns with the Centers for Medicare & Medicaid National Correct Coding Initiative, or NCCI, program to 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 the CMS Procedure to Procedure NCCI List. Only select codes allow modifier 59 and related X modifiers to automatically bypass the NCCI code-pair edits.

The 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 doesn’t 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. Health care 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 with the necessary documentation. Also, continue to fax one appeal at a time to avoid processing delays.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.