CurrentEmblemHealthPolicy N/A

Coding Validation

This policy governs EmblemHealth's claims editing program for validating CPT/HCPCS coding and appropriate use of modifiers (e.g., 24, 25, 59, XE/XS/XP/XU) on submitted claims and affects providers submitting claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyCoding Validation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 30, 2022

Next Review DateN/A

Key ActionIf you believe a claim was incorrectly denied due to modifier use, submit medical records so EmblemHealth can determine correct payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25,59,XE/XS/XP/XUOverriding modifiers

24,25,59,58,78,79Modifiers with guidelines

NCCI/CMS/AMASources cited

EnhancedProgram change

Modifier validation and claim payment stance

Policy Summary

PayerEmblemHealth

PolicyCoding Validation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 30, 2022

Next Review DateN/A

Key ActionIf you believe a claim was incorrectly denied due to modifier use, submit medical records so EmblemHealth can determine correct payment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Edits are based on correct coding rules published by national industry sources (AMA, CMS, NCCI) and are designed to detect potential coding errors and incorrect billing practices.

ALL of the following

Coding Validation reviews the information on the claim and in the patient’s claim history to determine if a modifier has been used correctly.
Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier; a modifier shall not be appended solely to bypass an NCCI PTP edit.

Overriding modifiers evaluated

Modifiers 25, 59, XE, XS, XP, XU comprise many of the overriding modifiers appended to services and are specifically evaluated by coding validation edits.

Modifier 25 criteria

Modifier 25 may be appended to indicate a significant, separately identifiable E/M service by the same physician on the same day as a procedure; the E/M must meet key components (history, examination, medical decision making) and be supported by documentation and an appropriate diagnosis code.
Documentation must support that the E/M is above and beyond the usual preoperative and postoperative care associated with the procedure.

Modifier 59 / XE/XS/XP/XU criteria

Modifier 59 (and the XE/XS/XP/XU subsets) should be used when the physician needs to indicate that a procedure or service was distinct or independent from other services on the same day (different session, encounter, site, lesion, practitioner, or other appropriate circumstance).
When clinically appropriate to utilize an NCCI PTP-associated modifier, both column one and column two codes may be eligible for payment; otherwise the column two code is denied per NCCI PTP edits.

Modifier 24 guidance

Modifier 24 may be used to indicate that an E/M service performed by the surgeon during the global period is unrelated to the surgery; append to the E/M code only and use for E/Ms starting the day after a procedure.
Modifier 24 must not be used for visits and services included in the global surgery package (for example, treatment of surgical complications, suture removal, or when the medical record shows the E/M is related to the surgery).

Post-operative modifiers (58, 78, 79)

Modifier 58: staged or related procedure/service by the same physician during the postoperative period.
Modifier 78: unplanned return to the operating/procedure room by the same physician for a related procedure during the postoperative period.
Modifier 79: unrelated procedure/service by the same physician during the postoperative period.

If providers believe claims were incorrectly denied due to modifier use, submit medical records so EmblemHealth can determine the correct payment for those claims.

Modifiers and coding guidance

Modifiers discussedModifier

Modifier 24	E/M service unrelated to surgery during global period when performed by the surgeon.
Modifier 25	Significant, separately identifiable E/M service by same physician on same day as procedure.
Modifier 59	Distinct procedural service; used when services that are not normally reported together are appropriate together.
Modifiers XE/XS/XP/XU	Subset of modifier 59 indicating different encounter (XE), separate structure (XS), separate practitioner (XP), or unlisted/other (XU) distinctions.
Modifiers 58, 78, 79	Post-operative period procedure/service relationship: staged/related (58), unplanned return (78), unrelated (79).

Modifier validation guidanceModifier

Modifier 25	E/M service must meet key components (history, exam, medical decision making) and be supported by documentation and diagnosis code.
Modifier 59	May permit payment of column two NCCI PTP code when clinically appropriate; indicates services not normally reported together (different session, site, incision, lesion, or encounter).
Modifier 24	Appended to the E/M code for services by surgeon during global period that are unrelated to the surgery; not for normal post-op services.

Modifier definitions and post-operative modifiers

inv-04: Modifiers 25, 59, XE, XS, XP, XU — overriding modifiers (listing)

Overriding modifiers coveredModifiers 25, 59, XE, XS, XP, XU are identified as the primary overriding modifiers evaluated by EmblemHealth's coding validation edits.

Purpose of evaluationModifiers are evaluated for correct clinical justification and documentation and must not be appended solely to bypass NCCI PTP edits.

Authority referencedPolicy follows national coding guidance from AMA, CMS, and the NCCI Policy Manual for modifier use.

Claim review processCoding Validation reviews claim information and patient claim history to determine correct modifier use.

Provider recourseIf providers believe claims were incorrectly denied due to modifier use, submit medical records for review.

inv-05: Modifier 25 — indicates a significant, separately identifiable E/M service provided by the same physician on the same day as a procedure.

DefinitionModifier 25 indicates a significant, separately identifiable E/M service provided by the same physician on the same day as a procedure or other service.

Documentation requirementsThe E/M service must meet key components (history, examination, medical decision making) and be supported by adequate medical record documentation and a diagnosis code.

Relation to procedureModifier 25 is used when the E/M service is 'above and beyond' the usual preoperative and postoperative care associated with the procedure.

CPT guidanceCPT states that evaluation services necessary before a procedure are included in the procedure code descriptor unless a separate significant E/M is performed.

inv-06: Modifier 24 — E/M services by the surgeon during the global period that are unrelated to the surgery.

DefinitionModifier 24 is used to report an E/M service by the surgeon during the global period that is unrelated to the surgery.

When to appendAppend modifier 24 to the E/M procedure code only; use for E/M services starting the day after a procedure.

Documentation standardDocumentation must support that the service is for treatment of the underlying condition and not a normal postoperative service.

Inappropriate usesDo not use modifier 24 for visits included in the global surgery package (e.g., treatment of surgical complications, wound care, suture removal) or when the medical record shows the E/M is related to the surgery.

inv-07: Modifier 59 / XE/XS/XP/XU — distinct or independent procedures/services on same day; may allow payment when appropriately used.

PurposeModifier 59 and modifier subsets XE, XS, XP, XU are used to indicate a procedure or service was distinct or independent from other services on the same day.

NCCI PTP interactionNCCI PTP edits deny the column two code when two codes in an edit pair are billed together unless an appropriate modifier justifies payment of both column one and column two codes.

Modifier 59 scopeModifier 59 identifies procedures/services not normally reported together but appropriate under the circumstances (different session, site, lesion, structure, or encounter).

XE/XS/XP/XU distinctionsXE: separate encounter; XS: separate structure; XP: separate practitioner; XU: Unusual non-overlapping service — these are subsets of modifier 59 to better describe the distinct circumstance.

inv-08: Post-operative modifiers — Modifiers 58/78/79: staged/related, unplanned return, or unrelated procedures during postoperative period.

Modifier 58Staged or related procedure or service by the same physician during the postoperative period.

Modifier 78Unplanned return to the operating or procedure room by the same physician following the initial procedure for a related procedure during the postoperative period.

Modifier 79Unrelated procedure or service by the same physician during a postoperative period.

Claim preparation noteEnsure appropriate diagnosis codes are assigned and modifiers are used only in accordance with published guidelines when preparing claims for submission.

OpenPayer

Coding Validation

Modifier validation and claim payment stance

Modifiers and coding guidance

Appeals and documentation requests

Modifier definitions and post-operative modifiers