CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

Defines BCBSRI professional claim requirements and documentation submission rules when reporting modifier 59 or the X{EPSU} modifiers (XE, XP, XS, XU) to indicate distinct/non-overlapping services on the same date of service; applies to providers submitting professional claims to Blue Cross & Blue Shield of Rhode Island.

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 ActionSubmit supporting medical record portions (location, procedural description/technique, and time) with the claim when reporting modifier 59 or an X{EPSU} modifier; claims without documentation will be rejected/denied and must be re-filed as a paper claim with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

08/15/2018documentation requirement start

5 listedexample codes

180timely filing limit (days)

Professionalclaim type

Documentation & Payment Criteria

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Documentation and payment criteria for modifier 59 and X{EPSU}

Claims handling and payment eligibility when modifier 59 or X{EPSU} modifiers are used:

BCBSRI follows CMS NCCI Procedure-to-Procedure (PTP) edits; column 2 codes are denied unless modifier 59 or an appropriate X{EPSU} modifier is appended to indicate services are separate and distinct.

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

Claims submitted electronically with modifier 59 or X{EPSU} without supporting documentation will be rejected/denied; denied electronic claims must be re-filed as a paper CMS-1500 claim with the supporting documentation to BCBSRI Claims Department.

To be considered for benefit payment, submit a clean claim (or paper claim with supporting documentation) within 180 days of the date of service or completion of an inpatient stay; encounter claims must also be received within the same timeframe.

ALL of the following

Do not append modifier 59 when a more descriptive X{EPSU} modifier is available; use the appropriate X{EPSU} modifier (XE, XP, XS, XU) instead.
Do not report both modifier 59 and an X{EPSU} modifier on the same line.
Modifier 59 should not be appended to E/M services; use modifier 25 to report a separate and distinct E/M service on the same date as a non-E/M service.

Documentation standard — records must support that the services were distinct by demonstrating at least one of: different procedure/surgery, separate patient encounter/session, different site or organ system, separate incision/excision, separate lesion, or separate injury/area of injury.

Modifiers and Example Codes

Example codes requiring documentation when billed with modifier 59 or X{EPSU}CPT

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

Use of modifier 59 vs X{EPSU}

RuleUse X{EPSU} modifiers when a more descriptive modifier is available; do not append both modifier 59 and an X{EPSU} modifier to the same line.

When to use 59Modifier 59 identifies distinct procedural services (non‑E/M) when no more descriptive modifier is available; it should not be appended to E/M services.

Relationship to NCCIBCBSRI follows CMS NCCI PTP edits: column 2 codes are denied unless modifier 59 or an appropriate X{EPSU} is appended to indicate services are separate and distinct.

Documentation requirementWhen modifier 59 or an X{EPSU} is appended to certain codes, providers must submit supporting documentation (location, procedural description/technique, and time) at claim submission or the claim will be rejected/denied.

Effective date for documentation ruleBeginning 8/15/18 BCBSRI requires documentation for certain services billed with these modifiers.

Documentation Submission & Claim Filing

Documentation Required

Submit supporting medical record when using modifier 59 or X{EPSU}

When modifier 59 or an X{EPSU} modifier is appended to certain codes (or when such a modifier is used and another listed code is also on the claim), submit the portion of the medical record that supports the separate and distinct procedure — including location (different region), procedural description/technique, and time — at the time of claim submission; claims submitted without supporting documentation will be rejected/denied and must be re-filed as a paper claim with supporting documentation.

Required documentation: portion of the medical record showing location (different region), procedure description/technique, and time.
Electronic claims received without supporting documentation will be rejected/denied.
Denied electronic claims must be re-filed as a paper claim with the supporting documentation.

Billing Rule

Paper claim filing instructions and timely filing limit

Complete a CMS-1500 claim form and mail the paper claim with supporting documentation to Blue Cross & Blue Shield of Rhode Island Claims Department, 500 Exchange Street, Providence, RI 02903; submit within 180 days of the date of service or completion of an inpatient stay (encounter claims must also be received within the same timeframe) to be considered for benefit payment.

Use CMS-1500 for paper filing.
Mail to: Blue Cross & Blue Shield of Rhode Island Claims Department, 500 Exchange Street, Providence, RI 02903.
Paper claim and supporting documentation must be submitted within 180 days of date of service or discharge; late claims will be denied.

Modifier Definitions

Modifier 59

Primary guidanceModifier 59 should be used to identify distinct procedural services (non‑E/M) when no more descriptive modifier is available.

Do not use with E/MModifier 59 should not be appended to an E/M service; use modifier 25 to report a separate and distinct E/M service on the same date as a non‑E/M service.

Common misuseModifier 59 should not be appended simply because two codes represent different procedures/surgeries if they occur at the same anatomic site and patient encounter.

NCCI contextUnder NCCI PTP edits the column 1 code is eligible for payment and the column 2 code is denied unless modifier 59 or X{EPSU} is appended to the column 2 code.

XE/XP/XS/XU

Use X{EPSU} when availableX{EPSU} modifiers (XE, XP, XS, XU) are more selective subsets of modifier 59 and should be used instead of modifier 59 when they accurately describe the distinct circumstance.

DefinitionsXE: separate encounter; XP: separate practitioner; XS: separate structure; XU: unusual non‑overlapping service.

Mutual exclusivityIt is incorrect to report both modifier 59 and an X{EPSU} modifier on the same line.

NCCI relationshipCMS established X{EPSU} modifiers to provide more specific explanations to support payment of column 2 codes under NCCI PTP edits.

Modifier 25

DefinitionModifier 25 is used to report a separate and distinct E/M service on the same date as a non‑E/M service.

When not to use 59Modifier 59 should not be appended to E/M services; use modifier 25 for separate E/M services instead.

Example contextBCBSRI follows CPT guidance that distinguishes modifier 25 for E/M vs modifier 59/X{EPSU} for non‑E/M distinct procedural services.