Modifiers 59, XE, XP, XS, XU: Distinct Procedural Services
Defines Anthem Medicare Advantage reimbursement guidance for use of Modifier 59 and X{EPSU} (XE, XP, XS, XU) to indicate distinct procedural services when billed by the same provider on the same day; applies to Anthem Medicare Advantage providers and claims processing in applicable states.
No material clinical or coverage changes in this revision.
Reimbursement for Distinct Procedural Services
Reimbursement criteria for distinct procedural services
Covered when ALL of the following are met:
Modifier and Coding Guidance
| Modifier 59 | Used to identify procedures/services, other than E/M services, that are not normally reported together; use only if no more descriptive modifier is available. |
| Modifier XE | Separate encounter — service distinct because it occurred during a separate encounter. |
| Modifier XP | Separate practitioner — service distinct because it was performed by a different practitioner. |
| Modifier XS | Separate structure — service distinct because it was performed on a separate organ/structure. |
| Modifier XU | Unusual non-overlapping service — distinct because it does not overlap usual components of the main service. |
Authorization, Documentation, and Post-Payment Review
Post-payment review: documentation may be requested and payments recouped
Anthem Medicare Advantage reserves the right to perform post-payment review of claims submitted with Modifier 59 and X{EPSU}. Providers may be asked to submit additional documentation, including medical records; failure to provide requested documentation or documentation that does not support the billed services may result in denial and recovery/recoupment of payment. Anthem is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation.
- May request additional documentation (including medical records) to support billed services.
- If documentation is not provided or does not support billed services, Anthem may deny the claim and recover/recoup payment.
- Anthem is not liable for interest or penalties when payment is denied or recouped due to provider failure to submit documentation.
Ensure authorization, medical necessity, and compliant coding
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and be consistent with the member's state of residence; provider, state, federal, or CMS contracts and requirements may supersede this policy. Claims must use industry-standard, compliant CPT/HCPCS/revenue codes and be fully supported in the medical record or office notes.
- Follow authorization and medical necessity requirements for the procedure and diagnosis and the member's state of residence.
- Use industry-standard, compliant CPT, HCPCS, and/or revenue codes on all claim submissions with supporting medical records.
- Policy may be superseded by provider, state, federal, or CMS contracts and requirements.
Modifier Definitions
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