-X {ESPU} New HCPCS modifiers—not an alternate ESPN channel

There was already confusion about the correct use of surgical modifier 59. Physicians and coders often appended the modifier to a second procedure, whether it was needed or not, just to be safe. It was like applying a Band-Aid, even when the skin wasn't broken. The CPT definition of modifier 59 is a distinct procedural service.  (See the full CPT definition below). CMS tells us that it is the modifier of last resort, to be used only when another modifier doesn't more accurately describe the situation. It should be used when a second procedure is a component code of the primary procedure but the second procedure  meets the requirements of distinct.

To add to the existing confusion, CMS released a transmittal in August 2014 defining four new modifiers called the –X{EPSU} modifiers which will eventually replace modifier 59. CMS made the change because it identified a high error rate in the use of modifier -59. However, CMS did not make the use of these modifiers mandatory. Some Medicare Contractors and private payers will begin phasing in these modifiers. Medical practices will have to check with their contractors to see if they must use the modifiers.

Here is an overview on the four –X{EPSU} modifiers that will replace modifier 59:

1. XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
   Use modifier –XE when the second procedure was performed at a different encounter and is not described more accurately by modifier 24, 25, 27, 57, 58, 78, 79 or 91.
2. XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
   In an article about modifier 59, CMS states that in order to use modifier 59 for different anatomic site, the procedures must be those that are not usually performed together or when the services are on different anatomic regions. They give three examples of treatment of a single anatomic site: treatment of the nail, nail bed, and adjacent soft tissue, treatment of posterior segment structures in the eye, and arthroscopic treatment of structures in adjoining areas of the same shoulder.  It would not be correct to use modifier –XS in these examples. In order to use modifier –XS for the second procedure, the second procedure must be performed on a separate organ or structure.
3. XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
   Modifier –XP is used to report service that was performed by a different practitioner on the same calendar day as the first procedure. Because these four –X{ESPU} modifiers are in lieu of reporting modifier 59 they should only be reported when there is no other modifier which can be used. If any of the other surgical modifiers described the situation, use it.
4. XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service
   One example of the correct use of modifier -XU is when a diagnostic procedure precedes a therapeutic procedure and a diagnostic procedure is the basis for performing the therapeutic procedure. The diagnostic procedure must occur before the therapeutic procedure, must clearly provide the information needed to decide whether to proceed with a therapeutic procedure and must does not constitute a service which would otherwise have been required during the therapeutic procedure.  Do not report both if the diagnostic procedure is an inherent component of the surgical procedure.

CMS has not mandated the use of these modifiers. Individual Medicare Contractors may make their own decisions about the pace of adopting them. CMS itself said “CMS will continue to recognize the-59 modifier in many instances but may selectively require a more specific –X{EPSU} modifier for billing certain codes at high risk for incorrect billing.”  Examples of what CMS considers high risk billing are in their modifier 59 article, cited below.  Many surgical practices are continuing to use modifier 59, and are waiting to adopt these modifiers until more specific guidance is provided by their own Contractor. Private payers typically lag in adopting HCPCS codes and modifiers. Surgical practices should refrain from using these modifiers for their private prayers unless instructed to do so.

Additional Resources 
The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that 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) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

MedLearn Matters 8863 “Specific Modifiers for Distinct Procedural Services”  

CMS Transmittal 1422 8/15/14 “Specific Modifiers for Distinct Procedural Services”

Modifier 59 info from Medicare’s CCI Edits