It’s not just ICD-10 that’s requiring medical billing and coding to get a lot more specific! In August, Medicare made it clear to providers that they recognized the inadequacies of the 59 modifier (“distinct procedural service”) and introduced four new modifiers to ideally be used in its place: XE, XP, XS & XU. If your billers and coders are saying “X what?!” then it’s critical they get more familiar with the new medicare modifiers.
For background, the 59 modifier has long been one of the most misused modifiers in the revenue cycle management industry. Its intended use is to signify that that two or more procedures were performed on the same date of service for ‘distinct’ medical reasons, but it’s often used more manipulatively by practice management organizations to “unbundle” two related procedures to receive higher reimbursement.
The 59 modifier is not being eliminated, but with the introduction of the four replacement modifiers it’s obvious, Medicare is trying to lessen the misuse of the more general “distinct procedural service” and lower associated denials and claim resubmissions. The key is to drill down to why the procedural service is distinct, and to use the appropriate modifier. Here’s how the four new modifiers shake out and examples of how each should be used.
XE: Separate Encounter
Let’s say a patient comes to your office with a nosebleed and the physician performs a diagnostic nasal endoscopy (31231). You wouldn’t code the claim for both the cautery of the nosebleed (30903) and the endoscopy, since handling and eliminating the bleeding is a given part of the endoscopy procedure.
But what if the physician performed the nasal endoscopy during a 9 a.m. appointment and the patient shows back up at your office at 3 p.m. requiring cauterization? In that instance, you’ll indicate to the payer that two encounters took place by using the XE modifier.
XP: Separate Practitioner
Using our above example, imagine that both a doctor and a nurse are in the exam room for the 9 a.m. appointment. After Dr. A performs the endoscopy and steps away, there’s a small problem requiring the nurse to re-cauterize the nosebleed. Using the XP code would enable your practice to indicate that a distinct cautery procedure took place and that it was performed by a different provider.
XS: Separate Structure or Organ
This one’s pretty straightforward: same procedure, two different parts of the body. This modifier will be used frequently by practices in the dermatology space: If you remove a lesion from a patient’s shoulder, then remove one from his upper arm, the XS modifier will distinguish that two distinct regions of the body were involved in the encounter.
XU: Unusual Non-Overlapping Service
As its name suggests, this modifier is a little more complex to understand. Medicare has issued limited guidance on the matter, but the prevailing understanding is that XU’s use is appropriate in instances when a service is distinct because it does not overlap usual components of the main service (i.e., treatments to two separate but similar injuries during the same operative session) or when a diagnostic procedure results in the need for a therapeutic or surgical procedure later in the day.