CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Modifier 59, XE, XP, XS, XU Guidelines

Governs claim submission and documentation requirements when modifier 59 or X{EPSU} modifiers (XE, XP, XS, XU) are used on professional claims for BCBSRI; affects providers submitting professional claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Modifier 59, XE, XP, XS, XU Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2019

Next Review DateN/A

Key ActionClaims with modifier 59 or X{EPSU} appended to listed codes must be filed on paper with supporting documentation (e.g., operative/medical notes).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

08/15/2018Documentation requirement began

RequiredPaper submission

180 daysClean claim timeframe

5 codesExample code list

Documentation and Payment Criteria

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Supporting documentation: When modifier 59 or an X{EPSU} modifier is appended to a listed code, or when modifier 59/X{EPSU} is appended to a code and one of the listed codes is also present on the same claim, providers must submit the portion of the medical record that supports the separate and distinct procedure (location/different region, procedural description/technique, and time) at time of claim submission.

Paper submission required: All claims submitted with modifier 59 or X{EPSU} appended to one of the listed codes must be filed on paper with supporting documentation (e.g., operative/medical notes). Electronic claims or claims filed without supporting documentation will be rejected/denied and must be re-filed as a paper claim with documentation.

Timing: To be considered for benefit payment, a clean claim must be submitted within 180 days of the date of service or completion of an inpatient stay (encounter claims must also be received within the same timeframe). Claims submitted after the time limit will be denied.

Use of X modifiers vs 59: Use the more descriptive X{EPSU} modifier (XE, XP, XS, XU) when appropriate. Do not append both modifier 59 and an X modifier on the same line. Modifier 59 should not be used when a more descriptive modifier is available; do not append modifier 59 to E/M services (use modifier 25 for separate E/M services).

NCCI PTP effect: Under NCCI PTP edits, when two codes from an edit pair are reported for the same patient on the same date, the column 1 code is eligible for payment and the column 2 code is denied unless the column 2 code has modifier 59 or an appropriate X{EPSU} with supporting documentation demonstrating distinct and separate service.

Operational filing instruction: Complete a CMS-1500 claim form and submit the paper claim and supporting documentation to Blue Cross & Blue Shield of Rhode Island Claims Department, 500 Exchange Street, Providence, RI 02903 for review.

Example Codes and Filing Timeframe

Covered CPT CodesCPTCovered

43239	Esophagogastroduodenoscopy, flexible, transoral; with single or multiple
45380	Colonoscopy, flexible; with single or multiple biopsy
76942	Ultrasonic guidance for needle placement (eg, aspiration, injection, localization device), imaging supervision and interpretation
70544	Magnetic resonance angiography, head; without contrast material(s)
92250	Fundus photography with interpretation and report

Claim submission timeframe

Timeframe to submit a clean claim180 days from date of service or completion of an inpatient stay (encounter claims must be received within the same timeframe)

Paper filing requirement when modifier 59/X{EPSU} used on listed codesClaims with modifier 59 or X{EPSU} appended to one of the listed codes must be filed on paper with supporting documentation (e.g., operative/medical notes)

Rejected/Denied electronic claimsElectronic claims or claims filed without supporting documentation will be rejected/denied and must be re-filed as a paper claim with documentation

Filing and Documentation Requirements

Documentation Required

Paper Submission and Documentation Requirement

BCBSRI follows CMS guidelines regarding NCCI PTP edits and the appropriate use of Modifier 59 or X{EPSU}. Effective August 15, 2018, when Modifier 59 or X{EPSU} is appended to a listed code (or when Modifier 59 or X{EPSU} is appended to a code not on the list but one of the listed codes is also present on the same claim), the portion of the medical record that supports the separate and distinct procedure — including location (different region), procedural description/technique, and time — must be submitted at the time of claim submission. All claims with Modifier 59 or X{EPSU} appended to one of the specified codes must be filed on paper with supporting documentation (for example: operative notes, medical records) for review. Claims submitted electronically or submitted without supporting documentation will be rejected or denied by the claims processing system and must be re-filed as a paper claim with the required documentation.

Applicable when Modifier 59 or X{EPSU} is appended to one of the listed codes, or when Modifier 59 or X{EPSU} is appended to a code not on the list but a listed code is also present on the claim.
Required supporting documentation examples: operative notes, procedure reports, medical record excerpts documenting separate/distinct procedure (location, technique, time).
Claims submitted electronically with Modifier 59/X{EPSU} on affected codes or without documentation will be rejected/denied and must be refiled on paper with documentation.
Timeframe: To be considered for benefit payment, a clean paper claim with supporting documentation must be submitted within 180 days of the date of service or completion of an inpatient stay (encounter claims must also be received within the same timeframe). Claims submitted after the time limit will be denied.

Note

How to File

Process to file a paper claim:

Complete a CMS-1500 claim form.
Attach all supporting documentation (operative/medical notes) that demonstrate the separate and distinct nature of the procedure.
Mail the CMS-1500 and documentation to: Blue Cross & Blue Shield of Rhode Island Claims Department, 500 Exchange Street, Providence, RI 02903.

Modifier Definitions

Modifier 59

DefinitionModifier 59: Distinct Procedural Service — used to identify procedures/services, other than E/M services, that are not normally reported together but are appropriate under the circumstances; only use when no more descriptive modifier is available.

Documentation requirementsWhen modifier 59 is appended to a column 2 code subject to NCCI PTP edits, supporting documentation must demonstrate the separate and distinct procedure (location, technique, time) to be eligible for payment.

Usage cautionsModifier 59 should not be appended to an E/M service; use modifier 25 for separate E/M services. Do not append modifier 59 when a more descriptive X{EPSU} modifier is available or append both 59 and an X modifier on the same line.

X{EPSU} modifiers

XESeparate Encounter — Service that is distinct because it occurred during a separate encounter.

XPSeparate Practitioner — Service that is distinct because it was performed by a different practitioner.

XSSeparate Structure — Service that is distinct because it was performed on a separate organ/structure.

XUUnusual Non-Overlapping Service — Service that is distinct because it does not overlap usual components of the main service.